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Special Pop Exam 3 > Liver/GI Part 3 > Flashcards

Liver/GI Part 3 Flashcards

1
Q

__________ is the sole definitive treatment modality for patients with acute liver failure, ESLD, and primary hepatic malignancy.

A

Liver transplantation

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2
Q

___________ score is a validated system that UNOS uses for prioritizing patients on the liver transplant waiting list.

A

The Model for End-Stage Liver Disease (MELD)

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3
Q

The MELD score is a validated system that uses ___________________ to mathematically rank adult patients according to their expected survival rate without transplantation.

A
  • serum total bilirubin
  • serum creatinine
  • INR values
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4
Q

Three-Month Mortality According to MELD Score∗

A
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5
Q

Signs and symptoms of liver failure:

A

Anorexia, weakness, nausea, vomiting, abdominal pain, hepatosplenomegaly, ascites, jaundice, metabolic encephalopathy, spider nevi.
Ascites: aspiration of fluid may see big hemodynamic shifts

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6
Q

A patient with esophageal varices requires what specifics?

A

vasopressin, RSI intubation

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7
Q

what is the management for pt with ascites?

A
  • need volume expanders (albumin)
  • Na restrictions and slow diuresis
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8
Q

what pulmonary manifestations would you see with liver failure?

A

V/Q mismatch

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9
Q

Portal hypertension typically manifests as:

A

ascites, esophageal varices; hepatic encephalopathy

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10
Q

what are the CV manifestations a/w liver failure?

A
  • high cardiac output
  • high HR
  • low SVR
  • decreased RBF
  • extensive collaterals (esp lungs)
  • prolonged QT interval
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11
Q

what would you see with the renal dysfxn a/w liver failure?

A

no Na or free water secretion, vasoconstricts and causes sympathetic release

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12
Q

what is the anesthesia management like for liver transplants?

A

Standard monitors
A-line, large-bore IV access, CVC, PAC, cardiac output monitoring, POC ABGs, thromboelastogram (TEG), TEE, cell saver, rapid infuser, blood products (RBCs, FFPs, platelets, cryo)
PAC is gold standard in hemodynamic monitoring
Transfer to ICU on vent

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13
Q

Thromboelastogram (TEG)

A
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14
Q

whats included in the intraop management for a liver transplant?

A

Normovolemia
Coagulopathy: hyper- or hypocoaguable
Temperature: keep warm
Limited sedation
No contraindications to induction agents
Muscle relaxants
Opioid of choice
Post-induction hypotension
Altered pharmacokinetic and pharmacodynamic response
ICP monitoring

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15
Q

an autosomal recessive disease characterized by impaired copper metabolism.

A

Wilson Disease

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16
Q

α1-antitrypsin deficiency

A
  • genetic disorder that results in defective production of α1-antitrypsin protein
  • this protein protects the liver and lungs from neutrophil elastase, an enzyme that can disrupt connective tissue leading to inflammation, cirrhosis, and HCC.
  • In the lungs, patients with α1-antitrypsin deficiency can develop early-onset panlobular emphysema and symptoms of chronic obstructive pulmonary disease.
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17
Q

________ is a disorder associated with excess iron in the body that can lead to multiorgan dysfunction.

A

Hemochromatosis

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18
Q

Inborn Errors of Metabolism

A

Wilson Disease
α1-antitrypsin deficiency
Hemochromatosis

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19
Q

Most common cause of cholestasis is ________

A

obstruction of biliary tract outside of the liver

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20
Q

Diseases of the Biliary Tract

A

Suppression or cessation of bile flow
Most common cause of cholestasis is obstruction of biliary tract outside of the liver
Gallstones, stricture, tumor, infection, or ischemia

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21
Q

Cholecystitis: causes and S/S

A

Caused by obstruction, infection, or both
Acute cholecystitis usually related to gallstones 90-95% of the time
S/S include sudden right upper quadrant tenderness, fever and leukocytosis
Inspiratory efforts worsen pain – Murphy sign
Jaundice – complete obstruction of cystic duct
Charcot’s triad- fever/chills, jaundice, RUQ pain

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22
Q

Cholecystitis Anesthesia Management

A

Standard induction or RSI if N/V present
* OG to decrease stomach
Insufflation
* Decreased FRC, CC and increased PIP, hypotension
* 15 mmHg routine, higher decreases CO, PreLoad
* Increased risk of gastric reflux
Reverse Trendelenburg
* Decreases venous return

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23
Q

Contraindications to a lap cholecystectomy

A

Coagulopathy, severe COPD, ESLD, CHF

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24
Q

Achalasia

A

Impaired relaxation of LES
Chronic achalasia results in dilation of esophagus, more food and fluids retained- aspiration risk
disease of the esophagus

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25
Q

GERD

A

Failure of antireflux barriers
Can manifest as ENT or pulmonary symptoms
Chronic GERD can result in abnormal epithelial cells and predisposition to developing a malignancy

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26
Q

Anesthesia for Esophageal Disorders

A

Asymptomatic vs uncontrolled disease with reflux symptoms
Aspiration prophylaxis during induction and emergence
Modification of gastric acidity with preoperative medications

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27
Q

Peptic Ulcer Disease

A

Gastric ulcer is loss of mucosa due to inflammation
Approx 98% of peptic ulcer occur in the stomach and duodenum
H. Pylori infection is associated with development of 90% of duodenal ulcers and roughly 75% gastric ulcers

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28
Q

Peptic Ulcer Disease Common complications include:

A

Hemorrhage
Perforation
Obstruction

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29
Q

Gastritis: what is it? how do you treat it? what can be life-threatening?

A

Inflammatory disorder of gastric mucosa
Stress ulceration, stress erosive gastritis, and hemorrhagic gastritis
Hemorrhagic gastritis can be life threatening
Upper GI bleed needs treatment
RSI, Fluids, Blood? Platelets? FFP?
Protein pump inhibitors, H2 receptor antagonist

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30
Q

Gastric Ulcer Disease Most common complication is________

A

perforation

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31
Q

Develop from degeneration of stomach’s mucosal barrier against gastric acid

A

Gastric Ulcer Disease

32
Q

Gastric Ulcer Disease

A

Develop from degeneration of stomach’s mucosal barrier against gastric acid
Pain and anorexia predispose pt to wt loss and metabolic changes
Most common complication is perforation
Most occur in anterior aspect of lesser curvature

33
Q

_______ cancer 2nd most common cancer worldwide, 7th most in U.S.

A

Gastric

34
Q

Gastric Neoplastic Disease S/S

A

S/S include pain (constant, non-radiating and not relieved by food), wt loss, anorexia, fatigue, and vomiting

35
Q

Gastric Neoplastic Disease tX

A

Gastrectomy or partial gastrectomy (resection of tumor) remains the primary curative treatment

36
Q

Anesthetic Considerations for diseases of the stomach:

A

Many procedures are laparoscopic
Pts are usually acutely ill
Consider volume, albumin, usually anemic
Lab
Large IVs
T/C, have products available
Consider epidural for post-op pain management

37
Q

Anastamotic leakage risk factors:

A

anemias, co-morbidities, diabetics, vascular disease, decreased perfusion

38
Q

Postoperative ileus risk factors:

A

pain, anesthesia, manipulation of bowel contents, unbalanced electrolytes, immobility, intestinal wall swelling from IV fluids; prevention: start PO feeds as early as possible, early ambulation, minimize bowel manipulation

39
Q

Mesenteric traction syndrome s/s + tx:

A

tachycardia and hypotension; antihistamine and NSAIDS

40
Q

what kind of blood flow do you see to the intestines?

A

Splanchnic blood flow

41
Q

Zollinger-Ellison syndrome

A

Gastroduodenal and intestinal ulceration together with gastrin hypersecretion and a non-β islet cell tumor of the pancreas (gastrinoma)
Gastrin stimulates acid secretion through gastrin receptors on parietal cells and via histamine release; also excerts a trophic effect on gastric epithelial cells
Gastrinomas can develop in the presence of multiple endocrine neoplasia (MEN) type I, a disorder involving primarily three organ sites: the parathyroid glands, pancreas, and pituitary gland

42
Q

Abdominal Compartment Syndrome

A

Greater than 20mm HG intraabdominal pressure; normal pressure is less than 10mm HG
Measured with a bladder manometer
Organ dysfunction develops if longer than six hours; can lead to death
abdominal trauma, hemoperitoneum, mesenteric arterial thrombosis, acute pancreatitis, intestinal obstruction, visceral edema, and massive fluid volume replacement
Resuscitative efforts & exposure of the abdomen induce mesenteric edema formation and bowel dilation; delay closure until tension is resolved

43
Q

Carcinoid Tumors

A

Benign, slow growing
Symptoms related to space occupying
Usually originates in the GI tract
Usually asymptomatic
Can be metastatic
Hormones released are metabolized by the liver
Serotonin, histamine, kinin peptides

44
Q

Carcinoid Syndrome systemic effects:

A

Flushing, bronchoconstriction, hypotension, hypertension, diarrhea; life-threatening perioperative hemodynamic instability

45
Q

Carcinoid heart disease S/S:

A

Right sided cardiac involvement
Tricuspid and pulmonary valves
Tumors along valves
Bronchoconstriction
Metastasized by the lungs

46
Q

Carcinoid Syndrome Tx:

A

Octreotide: can be given IV; samatostatin
surgical excision, no chemo
Stress reduction: Carcinoid crisis
Avoid medications that increase release of hormones and mediators from tumor cells
Avoid meds that will release histamine

47
Q

Carcinoid crisis:

A

can necrose and release massive amounts of substances into circulations
Stress reduction can help prevent

48
Q

Alpha-adrenergic sympathetic stimulation inhibits _______

A

insulin secretion

49
Q

Exocrine digestive enzyme and endocrine hormonal capacity

A

Continuous secretion of 2.5 L of color, colorless, bicarbonate rich pancreatic juices (pH 8.3); main function duodenal alkalinization
Endocrine functional cells reside in the islets of Langerhans
Alpha cells secrete glucgon; Beta cells secrete insulin

50
Q

Insulin suppression results from:

A

Arterial hypoxemia
Hypothermia
Traumatic stress
Surgical stress

51
Q

_____ and ______ also inhibit insulin secretion

A

Beta-adrenergic sympathetic and Cholinergic blockade

52
Q

Insulin secretion is enhanced by:

A

Parasympathetic vagal stimulation
Beta adrenergic sympathetic activation
Cholinergic drub administration

53
Q

Acute Pancreatitis causes include:

A

alcohol abuse, trauma, ulcerative penetration, infection, vascular, metabolic disorders, autoimmune
80% of pancreatic disorder from alcohol and gallstones

54
Q

Acute Pancreatitis S/S include:

A

Abdominal distention
N/V
Pain
Hypotension
Hypovolemia

55
Q

Severe Acute Pancreatitis (SAP): what is it a/w? what is the main COD?

A

SAP associated with organ failure, local complications, prolonged ICU and 25% mortality rate
Multiple Organ dysfunction is main cause of death

56
Q

Describe the pain a/w pancreatitis and managing it.

A

Difficult to control pain from pancreatitis
will need narcotics, Morphine?, epidural analgesia
Pain radiates from midepigastric to periumbilical, can be worse in supine position

57
Q

Anesthetic Considerations for Pancreatic Disease:

A

Fluids and electrolytes resuscitation is imperative
Monitor labs
C-reactive Protein (CRP) > 150mg/L correlates with severity
ASA standard monitors, large IVs, consider CVP and A-line
Caution with medications that undergo hepatic biotransformation

58
Q

Chronic Pancreatitis most common etiology is _____

A

alcohol-70% of cases

59
Q

Chronic Pancreatitis S/S:

A

Abdominal pain
Wt loss
Malnutrition
Hepatic disease
Predisposed to pericardial and pleural effusions
Hypoalbuminemia
Hypomagnesemia

60
Q

Chronic Pancreatitis: WHAT IS IT?

A

Permanent and irreversible damage to the pancreas
Chronic inflammation, fibrosis, destruction of exocrine and endocrine tissue

61
Q

Pancreatic Tumors s/s

A

Painless jaundice
Dull aching midepigastric or back pain
Anorexia
Fatigue
New-onset DM is occasionally the 1st symptom

62
Q

Pancreatic Tumors

A

Pancreatic cancer 80-90% ductal adenocarcinomas
Can grow extensively before they produce symptoms
Generally resected by pancreaticoduodenectomy (Whipple)

63
Q

________ most common functioning tumor of the pancreas

A

Insulinoma

64
Q

Insulinoma s/s

A

Hypoglycemia
Seizures
Coma (symptoms of catecholamine release)

65
Q

Diagnostic Hallmark- Whipple triad S/S

A

Hypoglycemia (catecholamine release)
Low blood glucose (40-50 mg/do)
Relief after IV administration of glucose

66
Q

Whipple Procedure

A
67
Q

describe Splenic blood flow.

A

300mL/min and arises from splenic artery

68
Q

spleen function include:

A

blood filtering, maintenance of normal erythrocytes and immune processing of blood-borne foreign antigens

69
Q

Abnormal blood cells from disease such as sickle cell disease, thalassemia and spherocytosis removed by_________.

A

macrophages

70
Q

Splenic Disease can lead to ______

A

worsening anemia and symptomatic splenomegaly

71
Q

Pt undergoing splenectomy are at greater risk for post-op________

A

infection

72
Q

T/F the spleen is esstential for life

A

FALSE
Spleen not essential for life

73
Q

What is the most frequently injured abdominal organ?

A

Spleen is the most frequently injured abd organ
25-60% of adults intraabd trauma

74
Q

Injury to splenic artery can produce _______

A

lethal hemoperitoneum

75
Q

why is damage to the spleen important?

A

most vascular body organ, receiving 5% of the CO

76
Q

how can the spleen be removed if the pt is stable? Unstable?

A

Unstable/emergency laparotomy in a trauma to examine all abd organs
If stable, can be done laparoscopic, in lateral decubitus position
Caution with respiratory function, possible rib fractures for injury

77
Q

what are the considerations for the spleen removal?

A

Labs, fluid resuscitation, blood products available

Special Pop Exam 3 (6 decks)

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