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What provides protection to the lining of the stomach?
Mucous-bicarb level, surface epithelial cells, prostaglandins
What substances generally cause damage to the gastric mucosa causing PUD?
pepsinogen and HCl acid
When is acid secretion in the stomach greatest? Least?
- Greatest- night
- Least- morning
What 2 substances mediate gastric acid secretion?
- Ach and histamine
- Also due to stimulation
What are the 3 phases in which gastric acid is secreted?
- Cephalic phase- mediated by vagus, due to sight, smell, or taste of food
- Gastric phase- food distends the stomach wall and gastrin and acid are released
- Intestinal phase- food distends the intestinal wall
How does H. pylori cause duodenal ulceration?
Decreases bicarb secretion (which helps to protect the stomach against acid)
What % of pts with H. pylori develop PUD?
Complications of PUD?
What is the leading cause of death associated with PUD?
T or F, a pt with a GI obstruction does not need RSI?
F, they are considered full stomach
What occurs more frequently- gastric or duodenal ulcers?
Major trauma and shock, sepsis, respiratory failure, bleeding, multiple organ injury, burns, CNS injury is associated with acute ____ _____.
Major complication of stress gastritis?
Is PUD usually treated medically or surgically?
What meds are used in the treatment of PUD?
antacids, H2 antagonists, PPI, prostaglandin analogues, cytoprotective agents (sucralfate)
Risks associated with TUMS? (hint: they contain calcium)
How do H2 antagonists work?
Block H2 receptors which stimulate acid secretion
H. pylori treatment
Abx and PPI
What pts with PUD are candidates for surgical treatment?
complicated disease or unresponsive to medical treatment
What do all of the surgical treatments for PUD have in common?
All involve a vagotomy to denervate acid production
Is an active GI bleed considered a full stomach
Anesthesia plan for a pt requiring emergency surgery due to PUD complications
- Pre-medicate with H2 blocker
- Treat hypovolemia
- NDMR intra-op
- More opioids, less volatiles and propofol
- Hct may be hemoconcentrated...
- gastrin hypersecretion (stimulates HCl acid secretion)
- gastroduodenal and intestinal ulceration
- Non-islet cell tumor of the pancreas
- Secretes gastrin
What % of ppl with PUD have ZES?
Are PUD and ZES more common in males or females?
Patho of ZES
- Acid hypersecretion due to gastrin stimulation of receptors on the parietal cells, increased parietal cell mass. Histamine also involved (increases gastric acid).
- PUD and errosive esophagitis result
S/sx of ZES
- abd pain and ulcer in 90%
- diarrhea and reflux in 50%
How can ZES and PUD be differentiated?
Suspect gastrinoma (and ZES) if ulcers occur in unusual places like 2nd part of the duodenum and beyond
MENS (multiple endocrine neoplasias) type 1 is associated with what GI disease?
What effect does calcium have on gastric acid secretion and how does this r/t MENs type 1
- Ca++ stimulates gastrin secretion
- Pts with MENs may have hyperparathyroidism and associated hypercalcemia which will worsen their ulcers
fasting gastrin level
___ % of pts have metastatic tumors when diagnosed with ZES
PPI and surgical resection in the absence of MENS or mets
What are anesthetic considerations when a pt is having a gastrinoma excision?
- lyte abnormalities (hypo K, met alkalosis)
- MEN 1 considerations
- check labs, coats, LFTs
- PPI and H2 blocker (intra-op Zantac)
what are the 2 types of inflammatory bowel disease?
Crohns and UC
T or F, UC is confined to the large intestine
What part of the large intestine does UC usually affect?
- rectum and sigmoid 40-50%
- past the sigmoid 30-40%
- total colitis 20%
diarrhea, rectal bleeding, tenisthmus, mucous passage, crampy abdominal pain
What are complications of UC?
- Toxic megacolon
- Massive hemorrhage
- transverse colon dilates and there is loss of movement of contents thru the colon
- increased intraluminal pressure results
- mucosa becomes inflamed and systemic absorption of bacterial toxins occurs
Who is at risk for toxic megacolon?
UC pts receiving aggressive antibiotic therapy
CM of toxic megacolon
- abd distention
- absent bowel sounds
Toxic megacolon treatment
Mortality rate associated with TM
- emergent bowel resection
What part of the GI tract does Crohns disease typically affect?
Can affect any part (mouth to anus) but usually the terminal ileum
Crohn's disease s/sx
- recurrent RLQ pain
- palpable RLQ mass
2 patterns of Crohn's disease presentation
fistula formation or obstruction
How does fistula formation occur in Crohn's disease?
What affect does this have?
- Wall of the bowel becomes thin, small perforations develop, and a fistula forms
- Can go into adjacent loops of bowel, bladder, or an abscess
- This results in less SA to absorb nutrients and nutritional deficiencies
What are the extra-intestinal manifestations of Crohn's disease?
hepatomegaly, arthritis, ureteral calculi
What medication is the mainstay of treatment for mild to moderate UC?
sulfasalazine, both antibacterial and anti-inflammatory
abdominal contents travel thru pushing on lung parenchyma
What should be expected intra-op with diaphragmatic hernia repair?
Blood loss and large fluid shifts
Should a pt with a hiatal hernia be treated as full stomach?
- variation of a diaphragmatic hernia
- stomach herniates into chest
decreased resting tone of the LES
Normal resting tone of the LES?
LES resting tone with GERD?
What factors increase the risk of aspiration pneumonitis in a pt with GERD?
- Gastric contents > 0.4 ml / kg
- pH < 2.5
What drugs will increase LES tone?
succ, neostigmine, panc, reglan, metoprolol, prochlorperazine (compazine), alpha adrenergic stimulants
What drugs will decrease LES tone?
atropine, glyco, dopa, nipride, halothane, opioids, ?N20, propofol
tumor of the neural crest (cells that are neuroendocrine in origin and line the lumen of the GI and respiratory tracts)
Where are carcinoid tumors typically found?
What substances do carcinoid tumors contain?
GI peptides such as serotonin, prostaglandins, gastrin, insulin
What % of pts with carcinoid tumor have carcinoid syndrome? Why does it occur
- Result of massive amounts of circulating hormones reaching the systemic circulation
- Also get liver mets and liver can't metabolize the secreted hormones
Most common symptoms of carcinoid syndrome
flushing (sudden) and diarrhea
cardiac involvement, flushing, diarrhea
Why do wheezing and bronchoconstriction occur with carcinoid syndrome?
Due to serotonin and histamine over secretion
What drugs are helpful in treating carcinoid syndrome?
5HT3 antagonists (relieve diarrhea) and H1 or H2 blocker (relieve flushing)
What drugs can provoke a carcinoid crisis?
succ, epi, NE, dopa, isoproteronol
What drugs are safe to use with carcincoid syndrome (will not provoke a crisis)?
Prop, etomidate, vec, cisatro, roc, fent, remi, all volatiles
S/sx of carcinoid crisis
- intense flushing, abd pain, diarrhea
- tachycardia and hypo or hypertension
How is dx of carcinoid crisis made?
Urinary or plasma serotonin levels or amount of serotonin metabolite in the urine (5HIAA)
Can be false positive if eating a serotonin rich diet
- avoid conditions that cause flushing
- treat heart failure and wheezing
- control diarrhea- 5HT blockers might be helpful
What meds are useful in the treatment of carcinoid?
- serotonin antagonists
- somatostatin analogues (octreotide- prevents release of histamine and decreases stomach acid secretion)
Is there a cure for carcinoid?
Yes, surgery, only curative if no mets
Anesthesia management for carcinoid
- Pre-op echo to assess right sided heart disease
- A line
- Octreotide pre-op and intra-op
- Possible delayed emergence due to elevated serotonin levels
- Epidural ok but careful HD monitoring
Why is dx of carcinoid tumor often delayed?
- Symptoms are often vague
- Dx may be delayed for up to 2 years from the start of symptoms
Common causes of acute pancreatitis
ETOH abuse or gallstones
How can gall stones cause pancreatitis?
- Stones will obstruct the ampulla of vater
- This causes HTN of the pancreatic duct and leads to acute pancreatitis
What is the patho of pancreatitis?
Autodigestion by protease digestive enzymes that are part of the exocrine function of the pancreas
T or F, cystic fibrosis may be associated with the chronic form of pancreatitis?
- abd distention
- resp distress (pleural effusions and ascites)
- Hypotension (3rd spacing)
- Primarily by elevated serum amylase
- serum lipase is also elevated
What are the Ranson criteria?
- Used to identify risk of death from acute pancreatitis
- Factors include age, WBC, BUN, AST
- Amylase is NOT a factor
What diseases are part of the differential dx of pancreatitis?
- acute cholecystitis
- perforated DU
- mesenteric ischemia
- bowel obstruction
- acute MI
- aggressive fluid management (crystalloid and colloid)
- Enteral feedings via a J-tube
T or F, chronic pancreatitis can lead to diabetes
T, chronic inflammation causes the endocrine and exocrine functions to be impaired
What is cholelithiasis?
What is choledocholithiasis?
- gall stones
- stones in bile duct
What controls bile drainage into the duodenum?
The sphincter of Oddi
Risk factors for gall stones
- Western diet high in protein and cholesterol
S/sx of gallstones
- RUQ pain radiating to the back (biliary colic)
- Elevated WBC
- Jaundice possibly
In what age group is pyloric stenosis found in?
1st 6 mo of life
- Thickened pylorus (part of the stomach that connects to the duodenum) with gastric outlet obstruction
- HypoCl, hypoK metabolic alkalosis results
Pyloric stenosis treatment
- Full fluid and lyte replacement
- Surgical correction
- Full stomach!
Does a large or small bowel obstruction lead for more metabolic abnormalities
SBO as it is more involved with secretion and absorption than the large intestine
Is LBO or SBO more common?
Risks associated with LBO
Toxic megacolon and possible rupture
Anesthesia considerations with bowel obstruction
- Increased aspiration risk
- Increased intragastric pressure
- LES tone compromised
Bowel obstruction s/sx
- Abd distention
- Unstable HD
- Intraluminal gas-fluid in the lumen of the proximal segments of bowel
Free air in the peritoneum suggests what?
What intra-abd pressure is considered abd compartment syndrome
Problems associated with abd compartment syndrome?
- End organ dysfunction
- Decreased CO causing decreased GFR
- Decreased FRC and increased PIP
- Increased ICP
Mortality rate associated with abd compartment syndrome?
Causes of abd compartment syndrome?
abd trauma, infection with necrosis of abd viscera, repair of ruptured AAA, pancreatitis