Liver, Pancreas, Spleen Flashcards
2 functions of pancreas
- endocrine
- exocrine
pancreatic exocrine functions
-secretion of pancreatic juice (1500-3000 mL daily) from acinar cells that adjusts the pH of duodenal contents to promote optimal activity for pancreatic enzymes
pancreatic exocrine fluid content
- pH = 8.3
- sodium, potassium, bicarbonate, chloride
cholecystokinin-pancreozymin (CCK-PZ)
- released when acidic chyme arrives in small intestine
- produced by I-cells in duodenum
- slows stomach emptying, promotes bile and pancreas secretion
- creates the sensation of fullness during a meal (not between meals)
secretin
- released when acidic chyme arrives in small intestine
- produced by crypts of Lieberkühn in intestinal wall
- promotes bile and pancreas secretion
- plays a role in osmoregulation
pancreas endocrine cells (4)
- alpha: glucagon
- beta: insulin
- delta: somatostatin
- pancreatic polypeptide:
pancreatic polypeptide hormone function
-inhibits exocrine pancreatic secretion
somatostatin hormone function
-regulates GI function by restraining the rate nutrients are absorbed
glycogenesis
-storage of glucose as glycogen, occurs primarily in the liver and muscle
lipogenesis
-storage of fat as triglycerides, occurs primarily in the adipose tissue
gluconeogenesis
-formation of glucose from lactate, pyruvate, amino acids, glycerol
glycogenolysis
-breakdown of glycogen into glucose, occurs primarily in the liver
lipolysis
- the breakdown of stored triglycerides to free fatty acids and glycerol
- stimulated by lipase
hormones that oppose insulin (4)
- growth hormone
- cortisol
- glucagon
- epinephrine
factors that stimulate insulin release
- glucose, mannose, fructose
- amino acids
- gastrointestinal hormones
- acetylcholine
- beta-adrenergic stimulation
factors that inhibit insulin release
- hypoglycemia
- somatostatin
- alpha-adrenergic stimulation
blood glucose levels for diabetes diagnosis
- FBG > 126
- random glucose > 200
chronic complications of diabetes
- microvascular: retinopathy, nephropathy, neuropathy
- macrovascular: CAD, PVD, cerebrovascular disease
- other: infection, cataracts, stiff joint syndrome, glaucoma, poor wound healing
diabetic patient have _____ morbidity and mortality in the perioperative period compared with non-diabetes because _____
higher; organ damage associated with long term disease
the most common cause of perioperative mortality in the diabetic patient is?
ischemic heart disease
diabetes: preoperative considerations
- EKG
- medications for delayed gastric emptying
- assess neck mobility: glycosylation of tissues produces stiffness, ‘prayer sign’
- kidney function
- review of insulin medications
blood glucose above _____ may warrant surgery cancellation?
-350
diabetes: perioperative considerations
- impaired respiratory response to hypoxia
- schedule early in the day
- careful positioning
- hourly blood sugars
- denervation hypersensitivity of cardiac acetylcholine receptors place at risk for severe refractory bradycardia: consider with anticholinesterase reversal
hypoglycemia signs/symptoms
- tachycardia
- diaphoresis
- anxiety
- tremors
- pupillary dilation
- vasoconstriction
- piloerection
- confusion
- weakness
hypoglycemia treatment
- 25-50 mL of D50% IV
- D5% gtt
DKA
-type 1 DM
BG>250
-ketones - fruity breath, low pH, kussmaul respirations
-dehydration, hyperosmolarity
HHS
- type 2 DM
- BG>600
- dehydration, hyperosmolarity
mortality DKA versus HHS
-higher in HHS, may be due to HHS affecting an older population
acute pancreatitis signs/symptoms
- hemorrhage, edema, necrosis of pancreas
- induced auto-digestion
- pain
- n/v
- fever
- hypotension
- hypocalcemia with EKG changes (prolonged QT)
- acute renal failure
enzymes implicated in the syndrome of pancreatitis are activated by?
- trypsin
- enterokinase
- bile acids
pancreatic inflammation results from (4)
- vascular breakdown
- coagulation necrosis
- fat necrosis
- parenchymal necrosis
acute pancreatitis complications
- CV: pleural effusions, alterations in rhythm, thrombophlebitis, cardiac depression, s/s mimicking acute MI
- ARDS
- DIC
acute pancreatitis: pain control
- fentanyl
- NOT morphine: it causes spams of the Oddi sphincter
chronic pancreatitis: diagnosis triad
- steatorrhea
- pancreatic calcification
- diabetes mellitus
chronic pancreatitis: pseudocyst
- contains proteolytic enzymes
- best seen through CT
- not epithelial lined: therefore not true cyst
- high mortality
chronic pancreatitis: S/S
- hepatic disease: jaundice, ascites, esophageal varices, dereangements in coagulation factors
- cardiac and pleural effusions
- pancreatic abscesses
- intraabdominal hemorrhage
causes of pancreatitis mnemonic
- ‘I GET SMASHED’
- idiopathic
- gallstones
- ethanol
- trauma
- steroids
- mumps/malignancy
- autoimmune
- scorpion sting
- HLD, hypercalcemia
- ERCP
- drugs
ERCP: operative considerations
- done lateral or prone
- glucagon is given to relax sphincter of Oddi: 0.4-1 mg IV
Zollinger-Ellison Syndrome
-gastrinoma: over secretion of gastrin leading to over secretion of gastric acid
Whipple
-pancreaticoduodenectomy
C-peptide
- is a portion of the precursor to insulin
- tells if the body is making insulin
pancreatic transplant: anesthetic considerations
- multiple IVs, central line, A-line
- agents with minimal cardiac depressant effects and not metabolized in kidney
- high amount of opioids
- hemodynamics: cannot rapidly cause vascular expansion as this may result in allograft edema
- consider colloid
- heparin gtt
spleen zones (3)
- red pulp: splenic sinusoids
- white pulp: end arterial branches of central arteries, contain lymphocytes, macrophages, plasma cells
- marginal zone: ill defined zone that contains both
blood flow to spleen is?
300 mL/min
spleen physiologic functions
- blood filtering
- immune processing of blood-borne foreign antigens (IgM)
- hematopoiesis in fetus
- minor role in platelet storage
carcinoid tumors
- slow growing malignancies of enterochromaffin cells
- usually in the gastrointestinal tract, also lungs, pancreas, thymus, liver
factors that enhance carcinoid hormones
- direct stimulation
- beta adrenergic stimulation
carcinoid tumors: substances secreted by the enterochromaffin tumors
- serotonin
- bradykinin
- tachykinin
- prostaglandins
- ACTH
- histamine
carcinoid syndrome: symptoms
- cutaneous flushing
- bronchospasm
- labile BP
- diarrhea
- abdominal pain
- hyperglycemia
- hypoalbuminemia
carcinoid syndrome: diagnosis
serotonin metabolites in urine
carcinoid syndrome: anesthetic considerations
- histamine blockers
- avoid histamine agents
- avoid sympathomimetic agents
- hypotension with alpha not beta
- keep normothermic,
- monitor blood glucose
carcinoid syndrome: pretreatment
- octreotide: suppresses the release of tumor products, 100 mcg subq 2-3 times daily
- somatostatin: suppresses the release of tumor products
what cells line the hepatic sinusoids? what is each cells function?
- endothelial cells
- Kupffer cells: removes bacteria
liver blood flow
- 1500 mL per minute: 25-30% from artery, 70-75% from vein
- 25-30% cardiac output
liver as a reservoir - how much blood can the liver deliver in a time of need?
350 ml
liver: arterial versus venous differences
- arterial: autoregulation, alpha and beta receptors
- venous: flow from vein, alpha receptors
functions of the liver
- carbohydrate metabolism
- protein synthesis
- amino acid synthesis
- protein metabolism
- bile production
- lipid production
- coagulation factor synthesis
- drug metabolism
- bilirubin metabolism
phase 1 drug reactions
- hydrolysis, oxidation, reduction
- add or expose a functional group
phase 2 drug reactions
-conjugation
3 main complications from cirrhosis
- variceal hemorrhage
- fluid retention (ascites due to decreased plasma oncotic pressure)
- hepatic encephalopathy
muscle relaxation and liver disease
- NDMR: larger volume of distribution, may require more
- plasma cholinesterase may be deficient
the most profound etiologic factor that results in decreased hepatic blood bllod is?
-abdominal surgery
other factors that reduce hepatic blood flow (3)?
- hyptension
- excessive sympathetic activation
- high mean airway pressures during controlled ventilation
-sphincter of oddi spasm
- narcotic induced: morphine>Demerol>butorphanol>nalbuphine
- surgical manipulation
- cold irrigation
volatile agent of choice for liver disease?
-isoflurane
narcotic of choice for liver disease?
- fentanyl
- avoid morphine
portal hypertension treatment
- vasopressin 0.1-0.4 units/min
- octreotide: 50 mcg/hr: reduces blood flow to GI
fluid choice for liver failure?
- controversial
- NS: sodium retention
- LR can exacerbates liver failure secondary to the breakdown of bicarbonate in the liver
