Liver and GI Flashcards
What do you want to find out about regarding the GI history?
- Nutritional deficiency- wt loss greater than 10%
- N/V
- occult blood loss
- overt GI bleeding
- abd. pain/distension/masses
- dysphagia
- gastric hyperactivity with or without reflux
Who is consdered an aspiration risk?
- extreme ages
- ascites
- collagen vascular dx, metabolic disorders )DM, ESRD, hypothyroid)
- hiatal hernia/GERD/esophageal surgery
- mechanical obstruction
- prematurity
- pregnancy
- neurologic diseases
- morbid obesity
- severe pain/anxiety
- having eaten
What is the aspiration prophylaxis med plan?
- H2 antagonists
- sodium citrate (bicitra)
- metoclopramide
- omeprazole
What is Mendelson syndrome?
What are the risk factors?
How does it manifest?
- Chemical pneumonitis or aspiration pneumonitis caused by aspiration during anesthesia
- characterized by pH, volume, and gastric material aspirated
- Risk factors for aspiration sequelae:
- Gastric volume of 0.4 ml/kg
- pH <2.5
- Manifests as
- resp distress w/bronchospasm, cyanosis, dyspnea
- tachycardia
What is Barrett’s esophagus?
signs/symptoms
treatment
- metaplastic disorder of the esophagus secondary to reflux
- precursor to esophageal cancer
- S/S
- dysphagia
- reflux esophagitis
- retrosternal pain or heartbrn
- LES dystonia
- wt loss
- Treatment
- H2 blockers
- PPIs
- Nissen fundoplication
What is Schatzki Ring?
- a narrowing of the lower esophagus caused by a ring of mucosal tissue or muscular tissue
- causes dysphagia, food obstruction, vomiting
- aspiration risk
What is Gastroparesis?
What causes it?
- Partial paralysis of the stomach
- Causes:
- Vagus nerve injury
- autonomic neuropathy- diabetes (most common cause)
- Connective tissue dx (sclerderma, Ehlers-Danlos)
- Opioids, anticholinergics
- Will have prolonged food retention and up to 1 liter of fluid
- RSI! Intubate if even for a minor procedure
What is a hiatal hernia?
- stomach protrudes up into diaphragm
- sliding- food enters stomach from esophagus and gets caught in the pouch above the diaphragm
- symptoms:
- Heart burn
- regurgitation
- **can cause barrets esophagus and then cancer
- increases with age
What are peptic ulcers?
- Chronic lesions that can be anywhere in GI tract but 98% are in proximal duodenum and stomach (4:1)
- most commonly the duodenal bulb or antrum of stomach
- H. pylori is involved in 70-90% of duodenal ulcer and 70% of gastric ulcers
- Only 10-20% of ppl w/ H. Pylori get ulcers
What aggravates peptic ulcers?
- Age 45-60
- NSAIDS
- smoking
- alcohol
- corticosteroids
- high stress personality??
- gastrinoma (zollinger-ellison syndrome)
What problems do peptic ulcers cause?
- epigastric pain
- nausea and vomiting
- hemorrhage and perforation
- generally do NOT progress to cancer
- ** usually just impair quality of life rather than shorten it
- 15,000 deaths/year attributed to complications of peptic ulcers
Carcinoid tumors:
most common site
What is Carcinoid syndrome?
Symptoms of Carcinoid syndrome?
- GI tract- mostly common in appendix
- Carcinoid syndrome is caused when substances secreted in the GI tract enter systemic circulation
- bradykinin, histamine, serotonin, dopamine
- S/S of carcinoid syndrome
- cutaneous flushing
- diarrhea
- palpitations
- dyspnea, wheezing, bronchospasm
- hypotension
- HTN
- orthostasis
- right sided valvular heart dx
What is malnutrition often associated with?
- prolonged hospital stay
- wound infection
- abscess
- respiratory failure
- death
- Serum albumin <3.5
- <2.1 major predictor of morbidity in veterans undergoing non-cardiac surgery
- wt loss >10% in last 6 months
What should you look for on the pts hands when assessing GI?
- Koilonychia- brittle, thin nails that curve up
- Leukonychia- nails that have big white spots
- nail clubbing
- palmar erythema
- asterixis- can’t hold hand steady
- Dupuytren’s Contracture- palmar fascia becomes thick, causing fingers to curl and limiting function
During a GI physical, how should you do the abdominal examination? (we don’t really do this)
- auscultate bowel sounds
- palpate- note guarding and pain, note organomegaly
- percuss
Besides hands and abdomen, what else do you want to look at during a GI physical?
- Check sclera for jaundice or pallor
- Examine chest for gynecomastia or spider nevi- signs of liver dx
- skin color scratches, jaundice
- skin turgor
What are some general pre-op considerations for GI patients?
- Airway management and prevention of aspiration
- fluid and electrolyte balance
- Skin
- peripheral circulation
- HR, BP
- UOP
- kidney function
- orthostasis
What labs and monitoring do you want for a GI patient?
- Useful lab values:
- hematocrit
- serum electrolytes
- BUN
- serum albumin
- Monitoring
- +/- CVP, PAP
- +/- Art line
The liver does a lot of things. What are some of them?
- Reservoir of blood (10-15% total blood volume)
- maintains normal clotting
- mediates endocrine functions
- bilirubin excretion
- metabolism
- synthesis of proteins
- immunologic function
- pharmacokinetics
What do you want to know about the history of a pt with liver problems?
- easy bruising?
- anorexia or wt changes
- N/V or pain w/fatty meals
- pruritis or fatigue
- abdominal distension/ascites
- GI bleed
- scleral icterus, jaundice, or hx of it
- hepatmegaly or splenomegaly
- palmer erythema
- gynecomastia
- spider angiomata, petechiae, and ecchymosis
- prior blood tx
- recreational drugs/alcohol
- travel history
- occupational history
What medications can increase Liver enzyme levels (CYP450)
- antibiotics
- antiepileptic
- inhibitors of hydroxymethylglutaryl-coenzyme
- NSAIDS
- sulfonylureas for hyperflycemia
- herbals
- cocaine, ecstasy, angel dust, glues/solvents
How do you do a physical assessment of a liver pt?
Look at everything you would look at for a GI patient
What labs would be helpful with a liver pt?
- albumin
- CBC
- coags
- lytes and glucose levels
- serum liver enzyme
- serium ammonia levels
- platelet counts >100,000
- bilirubin
- ABG
- Normal lab Values
- albumin
- bilirubin
- unconjugated bili
- conjugated bili
- aspartate aminotransferase (SGOT)
- alanin aminotransferase (SGPT)
- alk phos
- prothrombin time
- Albumin 3.5-5.5 g/dl
- bili 0.3-1.1 mg/dL
- unconjugated bili 0.2-0.7 mg/dl
- conjugated bili 0.1-0.4 mg/dl
- SGOT 10-40 U/mL
- SGPT 5-35 U/mL
- alk phos 10-30 U/mL
- PT 12-14 sec
A currently non intoxicated alcoholic will require more/less anesthetic?
more
How do you determine if you should check LFTs?
(chart)
How do you determin what coags to look at?
(chart)
Would you get a pre-op EKG in a liver pt?
Why or why not?
- Yes
- incresed levels of endogenous vasodilators such as vasoactive intestinal peptide
- high CO
- decreased SVR
- hyperdynamic circulatory state
- arteriovenous shunting
- portal hypertension
What does the Child-Pugh score use to calculate morbidity and mortality with liver insufficiency?
What are the scores?
- encephalopathy
- ascites
- bilirubin
- albumin
- PT/INR
- primary biliary cirrhosis
- scored as A,B, and C- C being very severe
How does cholestatic disease predispose Vit K deficiency?
What does this cause?
How is this treated?
- Absorption of Vit K depends on bile salt excretion into GI tract
- Vit K is required for coagulation factors to be made (II, VII, IX, X), without Vit K, pt will be deficient
- treatment is to correct with parental Vit K
- FFP is necessary for emergent surgery
What are some findings you would expect to see in a pt with cholestatic disease?
- increased peripheral vasodilation
- increased CO
- increased portal venous pressure
- decreased portal venous blood flow
Hep B treatment
Hep C?
Autoimmune hepatitis treatment?
- Hep B Treatment-
- based on age and severity
- Interferon
- Hep C treatment
- interferon and ribavirin
- Autoimmune hepatitis treatment
- Corticosteroids and AZT
What should your preop evaluation focus on for a pt with acute/chronic hepatitis?
- signs and symptoms of encephalopathy
- bleeding
- jaundice
- ascites
- hemodynamics
- labs
- lytes, BUN/Cr, glucose, H&H, liver enzymes, bili, coags, ABG
What is the most common cause of chronic liver disease?
risk factors?
signs/symptoms
- Non-alcoholic fatty liver disease
- fat accumulation in the liver exceeding 5%
- Risk factors: NIDDM, obesity
- signs/symptoms
- asymptomatic, elevated AST/ALT
- some degree of hepatocyte necrosis which promotes the accumulation of inflammatory cells in liver
- leads to cirrhosis
- weight loss (even 5 lbs) can reverse the elevated liver enzymes
What are the 3 types of alcoholic liver disease?
How do you distiguish between?
S&S of all of them?
- Steatosis, alcoholic hepatitis, cirrhosis
- Clinical featureas do not distinugish, bust do liver biopsy for diagnosis
- S&S
- malaise
- nausea
- anorexia
- weakness
- abdominal discomfort
- hepatomegaly
- jaundice
How long after alcohol will a pt in withdrawal become tremulous?
hallucinations and seizure?
DTs?
How is this treated?
- tremulous within 6-8 hours
- hallucinaitons and z within 24 hours
- DTs within 72 hours
- treatment: benzos
How many ppl affected by cirrhosis?
most common causes of cirrhosis
S&S?
- affects 3 million- 12th leading cause of death
- most commonly due to Hep C and alcoholism
- alters the function of ALL organs in advanced stages
- anorexia, weakness, N/V, abd pain
- jaundice, ascites
- hyperdynamic circulation (High CO, low PVR, low SVR)
- portal hypertenison and shunting
