hepatobiliary/GI Flashcards
what are the 4 layers of the esophagus
- outer longitudinal layer
- inner circular muscular layer(smooth and striated muscle)
- mucosal lining (squamous epithelium, distal 1-2cm is columnar epithelium)
What is the concern with esophageal surgery?
close proximity to aorta
achalasia
failure of the lower esophageal sphincter tone to relax during swallowing accompanied with a lack of peristalsis
what causes achalasia
- DM
- stoke
- Amyotrophic lateral sclerosis
- connective tissue diseases
what happens to the epithelium in barret esophagus
normal squamous epithelium changes to metaplastic columnar epithelium
what causes barrett esophagus
chronic exposure to acidic gastric contents - GERD, chronic etoh, smoking
Barrett esophagus is closely associated with ____?
esophageal cancer
What medications are used to manage GERD?
PPI’s & H2 blockers
Failure of the LES to function properly, permitting stomach contents to reflux into the esophagus and possibly the pharynx is what condition
GERD
Weakness in the diaphragm that allows a portion of the stomach to migrate upward into the thoracic cavity is what condition
hiatal hernia
retrosternal pain of a burning quality that commonly occurs after meals is a characteristic of what condition?
Hiatal Hernia
What are two surgical tx for hiatal hernia
nissen & fundoplication
Where is a epiphanic diverticula located
near the LES
where is a traction diverticula located
mid esophagus
where Is a zenker diverticula located
upper esophagus
what is the risk of esophageal diverticula?
places the pt at risk for pulm aspiration of regurgitated food and also from food/fluids ingested but sequestered within the pouch
what do chemo drugs such as danunorubicin and doxorubicin cause
chemotherapy induced cardiomyopathy
what can bleomycin cause
pulmonary fibrosis, restrictive defect, increased potential for O2 toxicity.
anesthetic consideration for extubating a patient with esophageal disease
Patient must be fully awake and have demonstrated conscious control of the airway prior to extubation.
anesthetic consideration for intubating a patient with esophageal disease
- ETT to create a sealed airway to prevent the risk from passive regurg and aspiration
- RSI with cricoid pressure
what types of intraop complications are associated with esophageal cancer?
- hemorrhage
- injury to the tracheobronchial tree
- RLN injury
what types of post-op complications are associated with esophageal cancer
anastomic leak; mediastinities; pleural effusion, pneumonia, ARDs, cardiac and functional complications
Post-op tumor recurrence in patients with esophageal cancer:
not uncommon in patients undergoing curative resection for esophageal cancer - can be characterized as either loco regional (loco regional lymph node metastases, anastomic recurrence) or distant (hematogenous metastases, pleural or peritoneal seeding).
hematogenous metastases most commonly involve which organs
liver, lungs, bones. followed by adrenal glands, brain, and kidneys.
injury to the RLN places a patient at higher risk for?
aspiration pneumonia. impairs the ability of the patient to cough.
Mortality rates for esophageal resection have dropped from __% in the 1970s and early 1980s to __% in the late 1980s and early 1990s.
12 3
what are the most serious complications of esophageal resection?
anastomotic leak, mediastinitis and sepsis, and respiratory failure.
acid secretion of patietal cells depends on which energy pump
hydrogen/potassium (H+/K+) powered by ATP
acid release in the stomach is mediated by which three things
- vagal stim (ach)
- gastrin release (g cells in response to gastric distention)
- histamine
examples of H2 antagonists
cimetidine, ranitidine,
examples of H+/K+ ATP inhibitors
omeprazole, prostaglandins
what does vagotomy surgery do
diminishes parietal-cell response to gastrin and histamine
How is the gastric system a barrier against ingested pathogens
acidic environment, immunosurveillance
how is the gastric system a thermoregulator
heats or cools ingested substances
how does vitamin B12 play a role in the gastric system
parietal cells secrete intrinsic factor, facilitates ideal vitamin B12 absorption
the stomach is innervated by which nerve
vagus (X)
which disease is caused by erosion of protective mucous layer of the stomach and duodenum?
peptic ulcer disease
what causes peptic ulcer disease
- helicobacter pylori
- overuse of NSAIDS, ASA, and corticosteroids
- excessive etoh, tobacco, stress, radiation therapy
associated diseases with PUD
cirrhosis, chronic renal failure, zollinger ellison syndrome, hyperparathyroidism, chronic lung disease, chronic pancreatitis
what are the 3 components of milk-alkali syndrome
hypercalcemia, alkalosis, elevated BUN
how does milk-alkali syndrome manifest
skeletal muscle weakness and polyuria
oral antacids - how does acid rebound happen
gastric acid secretion may increase after existing acids are neutralized by calcium containing antacids
what do large amounts of aluminum containing antacids do to phosphorus levels
cause acute hypophosphatemia which manifests as skeletal muscle weakness and fatigue, pathologic fractures, osteoporosis
what drugs are given for PUD?
h2’s and PPI’s
how do H2 receptors work
block secretion of hydrochloric acid, promotes healing of duodenal ulcers.
how do h2’s interact w CYP450
may cause prolongation of the effects of concurrently administer drugs that rely on hepatic metabolism and elimination. famotidine is the least likely H2 antagonist offender
which drug binds to the ulcer, increases the gastric mucous layer, promotes the healing process, and is devoid of side effects?
sucralfate
what is Misoprostol used for
synthetic prostaglandin, secondary therapy to prevent ulcers in patients requiring NSAIDs
s/s of gastric neoplasms
anorexia and weight loss
majority of gastric neoplasms are classified as?
adenocarcinoma (95%)
which patients is increased gastric mucosal acidosis common in ?
critically ill,
pt undergoing prolonged, complex surgical procedure, pt undergoing CPB
gastritis associated with gastric mucosal acidosis is associated with
increased peri-operative morbidity and mortality
The abdominal viscera is particularly at risk to diminished blood flow (ischemia) and break down of the intestinal barrier may occur. Why is this concerning?
leads to translocation of bacteria and endotoxins into the bloodstream (sepsis)
what is the principle function of the pancreas
adjust duodenal pH
presence of acid in duodenum cause release of ___
secretin
presence of fats in duodenum causes release of ____
cholecystokinin
vagal stim to the pancreas causes release of
pancreatic enzymes
common causes of acute pancreatitis
- alchohol abuse
- direct or indirect traume
- ulcerative penetration from adjacent structures
- infectious processes
- biliary tract disease
- metabolic disorders
- drug side effect
pancreatitis s/s
extremely ill with severe abd pain, fever, nausea, vomiting, jaundice, hypotension, ileus, and external distortion of stomach on radiographs
acute pancreatitis management
- NG suction
- maintenance of intravascular volume
- anticipation of resp insufficiency
- analgesia
- nutritional support
- common bile duct exploration
s/s of chronic pancreatitis
incapacitating upper abd pain radiating to the back (continuous or intermittent in nature)
what condition causes steatorrhea
chronic pancreatitis
40% of patients with chronic pancreatitis have ___ From loss of pancreatic function
diabetes
common causes of chronic pancreatitis
- chronic alcoholism
- chronic, significant biliary tract disease
- long term effects of pancreatic injury
pancreatic cancer usually presents with
jaundice
what do gallstones look lik eon x-ray
radiolucent structures
regulation of gallbladder contraction is primarily hormonal thru the action of ______ which is released from dudenum and mediated by presence of intraluminal amino acids and fats
cholecystokinin
what are the three main functions of bile?
- emulsify and enhance absorption of ingested fats and fat-soluble vitamins
- provide an excretory pathway for bilirubin, drugs, toxins, and IgA
- maintain duodenal alkalization
how do patients present with cholecystitis
acute, severe, mid-epigastric pain that often radiates to the right abdomen
what is murphys sign
inspiratory effort accentuates cholecystitis pain
what would you expect labs to look like in someone with cholecystitis?
increase in plasma bilirubin, alkaline phosphatase, amylase, and WBC’s
gallbladder perforation may cause what 3 things
peritonitis, localized tenderness, or ileus
complete obstruction of the cystic duct will present as
jaundice
what is free abdominal air suggestive of
ruptured viscus with perf of gallbladder - requires emergency exp lap
charcot triangle is indicative of?
acute ductal obstruction.
charcot triangle symptoms
fever, chills, upper quadrant pain, weight loss, anorexia, fatigue.
cholecystitis is an acute obstruction of the ___ duct, while cholelithiasis is obstruction of ___ duct
cystic , common bile duct
increased intra-abdominal pressure causes ____ venous return
decreased
manipulation of abdominal visera may cause ___Cardia and ____tension
brady, hypo
laparoscopic surgery’s affect on ventilation
altered ventilatory dynamic caused by large volume of intra-abdominal carbon dioxide/hypercapnia
what type of embolism does laparoscopic surgery place pt at risk for
venous CO2 embolism
how does laparoscopic surgery increase risk of aspiration
abnormal gastroesophael junction competence from high intra-abdominal pressure
where does most digestion take place
small intestine
proteins and peptides are degraded into
amino acids
lipids are degraded into
fatty acids and glycerol
which disease is characterized by “cobble stoning”
crohn’s
which disease is characterized by pseudopolyps
UC
Chrons primary effects which part of the digestive track
SI and colon
which GI disease has a higher risk for smokers
chrons
which GI disease has a greater cancer risk
UC
UC effects which part of GI track
lower colon and rectum
intestinal surgery - avoid which gas
nitrous oxide
in the fetus, the spleen is a ____ organ
hematopoietic
