Liver/GI Flashcards
Who is an aspiration risk?
Age extremes under 1, over 70
Ascites, ESLD, collagen vascular disease, metabolic disorders (DM, obese, ESRD, hypothyroid)
Hiatal hernia/GERD esophageal surgery
Mechanical obstruction (pyloric stenosis, intestinal obstruction)
Prematurity, pregnancy, neuro disease, preop anxiety
What are the NPO guidelines.. 2h/4h/6h/ect? For healthy ASA 1/2 patients.
Sip of water/liquid up to 1h before OR Clears up to 2h before OR Breast milk up to 4h before OR Light meal, milk, formula up to 6h before OR No gum/candy after midnight
What are treatment options for aspiration prophylaxis?
H2 receptors antagonists: Cimetidine (Zantac) and famotodine-best, give night before and 45 min before surgery
Sodium citrate (bicitrate): raises gastric volume and pH, 15 min before surgery
Metoclopramide (reglan): dopamine antagonists increases pressure of lower esophageal sphincter, speeds gastric emptying, prevents N/V
Omeprazole (prilosec) - PPI
Mendelson Syndrome/ aspiration pneumonitis
Resp distress with bronchospasm, cyanosis, tachycardia, dyspnea from irritating action of HCl and particulate material that is damaging to lungs
Risk factors for aspiration sequelae include gastric volume of 0.4 ml.kg and pH less than 2.5
Barrett’s Esophagus: s/s and treatment?
S/S: dysphagia, reflux, retrosternal pain or heartburn, LES dystonia, weight loss
Tx: H2 blockers, proton pump inhibitors, nissen fundoplication (surgery)
This is a metaplastic disorder of the esophagus secondary to reflux, a precursor to esophageal cancer
Hiatal hernia s/s?
Retro-sternal discomfort
Burning after meals
This is a protrusion of a portion of the stomach through the hiatus of the diaphragm upward into the thoracic cavity
Peptic ulcer disease: What is it? Cause? Risk factors? S/S? Treatment?
Ulcerations in the GI mucosa, usually the duodenal bulb or antrum of stomach, cause is H. Pylori
Risk factors: age 45-60, use of NSAIDS, ETOH, steroids
s/s: epigastric pain, N/V, hematemesis/melena, abdominal tenderness, rigidity, perforation, weight loss
Treatment: H2 antagonisits, proton pump inhibitors, antimicrobial therapy, antacids
S/S of malabsorption syndrome?
Unexplained wt loss, steatorrhea, diarrhea, anemia, fatigue, vitamin K deficiency (check bleeding levels), bleeding dyscrasia, edema, ascities
Carcinoid syndrome: what is it, s/s?
In GI tract (also in appendix, pancreas or bronchi)
Symptoms bc of effects of hormones and substances secreted in GI tract: bradykinin, histamine, serotonin, dopamine
S/S: cutaneous flushing, unexplained tachycardia, diarrhea, palpitation, bronchospasm, dyspnea, hypotension/hypertension, orthostasis
Malnutrition is associated with what? What lab gives us a good idea of this?
Associated with prolonged hospital stay, wound infection, abscess, respiratory failure, death
Albumin level helps us predict morbility and mortality, less than 3.5 shows malnuturion, less than 2.1 shows morbidity for non-cardiac surgery
What does the liver do?
Vital reservoir of blood represents 10-15% total blood volume
Maintains normal clotting, mediates endocrine functions
Bilirubin excretion
Metabolism, synthesis of proteins
Immune function, pharmacokinetics
What are good questions to ask about to determine if someone has risk factors or symptoms of chronic liver disease?
History of jaundice, prior blood transfusions, recreational drugs/alcohol, current meds and herbals, family history of jaundice/liver disease, travel history, occupational history
What in the physical exam might you find in someone with liver disease?
Easy bruising, bleeding anorexia, weight loss/gain N/v, pain, pruritus GI bleed Jaundice, ascites, hepatitis, blood transfusion, dependent edema, asterixis (hand tremor, sign of liver encephalopathy)
What are two ways to score surgical morbidity and mortality with liver insufficiency?
MELD score and Child-Turcotte-Pugh score
Factors: encephalopathy ascites, bilirubin, albumin, PT/INR, primary biliary cirrhosis
How does alcohol use of the patient effect your anesthetic care?
These patients often require increased sedatives due to induced enzymes
They are commonly anemic as well
What is the cardiovascular status of a patient with liver dysfunction?
Increased levels of endogenous vasodilators such as vasoactive intestinal peptide
High CO, low SVR
Hyper-dynamic circulatory state
Arteriovenous shunting, portal hypertension
Get an EKG!
What does respiratory status look like in a patient with liver dysfunction?
Ascites impairs movement of the diaphragm resulting in decreased FRC
R to L shunting secondary to arteriovenous shunting
Cholestatic disease predisposes towards ______ deficiency. What is treatment and expected findings?
Vitamin K deficiency
Treatment: Vitamin K and FFP if needed
Expected findings: peripheral vasodilation, inc CO, inc portal venous pressure, dec portal venous blood flow
Long term biliary obstruction causes liver dysfunction interfering with protein synthesis
What are etiologies of hepatitis?
HBV, HDV, HCV, auto-immune, drug-associated
Graded based on degree of inflammation, necrosis, progression of disease and degree of fibrosis
Inflammation is over 6 months to be considered hepatitis
What are the 5 viruses that can cause viral hepatitis? What are s/s and treatment?
HAV, HBV, HCV, HDVHDV, HEV (most common in US is Hep C)
s/s: anorexia, N/V, low grade fever, dark urine, clay colored stool, jaundice, hepatic failure
Treatment: interferon, ribavirin
Non-alcoholic fatty liver disease risk factors?
Fat accumulation in liver over 5%
Risk factors: DM, obesity
Elevated liver enzymes, leads to cirrhosis
Weight loss can reverse the elevated liver enzymes
For alcoholic liver disease, what are s/s? What will a liver biopsy tell us?
s/s: malaise, N/V, anorexia, weakness, abdominal discomfort, hepatomegaly, jaundice
Liver biopsy tells us definitive diagnosis: steatosis (fatty liver), alcoholic hepatitis (precursor cirrhosis), cirrhosis
With cessation of drinking: Within ____ hours, pt may become tremulous. Within ____ hours, hallucinations and grand mal seizures occur.
DTs appear within ____ hours of withdrawal and are preceded by tremors, hallucinations, or seizures. Treatment is what?
6-8 hours tremors
24 hours hallucinations/seizures
72 hours DTs and withdrawl
Cirrhosis affects 3 million and is 12th leading cause of death, what is the most common causes? s/s?
Hep C and alcoholism
s/s: anorexia, weakness, N/V, abdominal pain, hepatomegaly, ascites, jaundice, spider nevi, metabolic encephalopathy, hyper-dynamic circulation (high CO, low PVR), gastroesophageal varicies, intrapulmonary shunting, V/Q mismatch, arterial hypoxemia due to intra-pulmonary vascular dilations, ascietes, edema, coagulation/endocrine disorder, hepatic encephalopathy, portal hypertension
