Liver/GI

Question 0

Who is an aspiration risk?

Answer 0

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

Question 1

What are the NPO guidelines.. 2h/4h/6h/ect? For healthy ASA 1/2 patients.

Answer 1

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

Question 2

What are treatment options for aspiration prophylaxis?

Answer 2

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

Question 3

Mendelson Syndrome/ aspiration pneumonitis

Answer 3

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

Question 4

Barrett’s Esophagus: s/s and treatment?

Answer 4

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

Question 5

Hiatal hernia s/s?

Answer 5

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

Question 6

Peptic ulcer disease: What is it? Cause? Risk factors? S/S? Treatment?

Answer 6

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

Question 7

S/S of malabsorption syndrome?

Answer 7

Unexplained wt loss, steatorrhea, diarrhea, anemia, fatigue, vitamin K deficiency (check bleeding levels), bleeding dyscrasia, edema, ascities

Question 8

Carcinoid syndrome: what is it, s/s?

Answer 8

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

Question 9

Malnutrition is associated with what? What lab gives us a good idea of this?

Answer 9

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

Question 10

What does the liver do?

Answer 10

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

Question 11

What are good questions to ask about to determine if someone has risk factors or symptoms of chronic liver disease?

Answer 11

History of jaundice, prior blood transfusions, recreational drugs/alcohol, current meds and herbals, family history of jaundice/liver disease, travel history, occupational history

Question 12

What in the physical exam might you find in someone with liver disease?

Answer 12

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)

Question 13

What are two ways to score surgical morbidity and mortality with liver insufficiency?

Answer 13

MELD score and Child-Turcotte-Pugh score

Factors: encephalopathy ascites, bilirubin, albumin, PT/INR, primary biliary cirrhosis

Question 14

How does alcohol use of the patient effect your anesthetic care?

Answer 14

These patients often require increased sedatives due to induced enzymes
They are commonly anemic as well

Question 15

What is the cardiovascular status of a patient with liver dysfunction?

Answer 15

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!

Question 16

What does respiratory status look like in a patient with liver dysfunction?

Answer 16

Ascites impairs movement of the diaphragm resulting in decreased FRC
R to L shunting secondary to arteriovenous shunting

Question 17

Cholestatic disease predisposes towards ______ deficiency. What is treatment and expected findings?

Answer 17

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

Question 18

What are etiologies of hepatitis?

Answer 18

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

Question 19

What are the 5 viruses that can cause viral hepatitis? What are s/s and treatment?

Answer 19

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

Question 20

Non-alcoholic fatty liver disease risk factors?

Answer 20

Fat accumulation in liver over 5%
Risk factors: DM, obesity
Elevated liver enzymes, leads to cirrhosis
Weight loss can reverse the elevated liver enzymes

Question 21

For alcoholic liver disease, what are s/s? What will a liver biopsy tell us?

Answer 21

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

Question 22

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?

Answer 22

6-8 hours tremors
24 hours hallucinations/seizures
72 hours DTs and withdrawl

Question 23

Cirrhosis affects 3 million and is 12th leading cause of death, what is the most common causes? s/s?

Answer 23

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

Question 24

In liver disease you have abnormalities in what 3 phases?

Answer 24

Hemostasis: inc bleeding time
Coagulation: factors 2/7/9/10 reduced, PT/INR elevated, thrombocytopendia, abnormal fibrinogen
Fibrinolysis: abnormal/dec platelet function

Question 25

Platelets are derived from the _____ in the bone marrow in response to ____ which is synthesized in the liver

Answer 25

Megakaryocytes

Thrombopoietin

Question 26

Where does vitamin K get absorbed?

What effect does vitamin K deficiency have on PT/PTT?

Answer 26

Vitamin K is fat soluble and requires bile salts for absorption into the jejunum
Vitamin K is necessary for the hepatic synthesis of factor 2/7/9/10 and protein S and C
Vitamin K deficiency causes prolonged PT/PTT