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102 Cards in this Set
- Front
- Back
Mallory-Weiss tear
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acute longitudinal tear of the esophagus caused by forceful retching
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what bacteria causes ulcer disease
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helicobacter pylori
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common causes of upper GI hemorrhage
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peptic ulcer disease, cirrhosis (portal htn), mallory-weiss tear, gastritis
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meds for upper GIB (IV gtts)
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vasopressin (constricts arterial bed, decreases portal venous pressure), octreotide (reduces splanich blood flow, gastric acid sxrn and motility)
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sclerotherapy
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agent is injected into varices, causing inflammation and later scar tissue
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balloon tamponade for varices, management
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HOB 45', pt can't swallow with tube in so frequent suctioning, scissors ready if balloon moves into pharynx and obstructs breathing,
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types of gastrectomy
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partial (Billroth I or II) or total
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Billroth I
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partial gastrectomy. antrectomy, vagotomy(resection vagus nerve) and gastroduodenostomy
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Billroth II
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partial gastrectomy. antrectomy, vagotomy (resectio vagus nerve) and gastrojejunostomy (stomach connects to jejunum)
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total gastrectomy
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gastrectomy with esophagus anastomosed to duodenum or jejunum
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early dumping syndrome
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common complicatino of gastrectomy. Problem is hyperosmolar dump of food into duodenum (absence pyloric valve), clammy & dizzy, tachycardia. 30 minutes post meal.
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late dumping syndrome
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hyperinsulinism effect r/t an increase in insulin production by the pancreas in response to a large bolus of food causing an increase in blood glucose, 2 hrs post meal, dizzy, clammy tachycardia
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TIPS procedure
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invasive angiographic method, connection made between hepatic and portal veins and a stent is paced in the tract. This decrease portal HTN (cause of esophageal varice bleed)
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Types of viral hepatitis (letters)
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A, B, C, D, E, F and G (very little known)
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Hepatitis A
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fecal/oral. Acute onset (never chronic). 99% resolves, supportive treatment.
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Hepatitis B
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parenteral/sexual/perinatal. Chronicity rare. Treatment: interferon, antivirals. Cancer in 20%.
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Hepatitis C
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parenteral/sexual/perinatal. Chronicity 50-60%. 40-50% develop cirrhosis, 20% liver failure. Treatment: interferon, corticosteroids.
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Hepatitis D
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superinfection in patient with chronic hepatitis B, same treatment as for Hep B.
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viruses that can cause acute liver failure
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fulminant hepatitis (all types), herpes simplex & zoster, Epstein-Barr, Adenovirus, cytomegalovirus
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hepatotoxic drugs that can cause liver failure
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acetaminophen, halothane, methyldopa, isoniazid, ectasy, toxins (mushrooms, sea anemone sting)
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Budd Chiari syndrome
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hepatic vein obstruction
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causes of acute exacerbation in chronic liver failure
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primary/metastatic tumors of liver, cirrhosis, Wilson's disease
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Wilson's disease
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genetic disorder where copper accumulates in tissues (causes liver disease and neuro stuff)
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cirrhosis
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liver parenchymal cells are destroyed progressively and are replaced with fibrotic tissue
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what % of liver can be destroyed (in cirrhosis) before symptoms appear?
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3/4
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How does cirrhosis cause portal HTN?
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distortion, twisting and constrictino of central sections cause impedance of portal blood flow
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fulminant hepatitis
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liver cells fail to regenerate and necrosis occurs
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If portal HTN causes splenomegaly, what problems can occur?
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thrombocytopenia (low platelets) and vitamin K deficiency
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When liver is unable to produce adequate amounts of bile and is impaired in protein, carb and fat metabolism (d/t portal HTN), what issues arise?
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1) serum bili is elevated because liver can't conjugate it and make bile. 2) deficiency of fat soluble vitamins may occur since bile salts aren't available. 3) hypoglycemia if liver can't produce fxn of glycogenolysis (carbs to simple sugars) and gluconeogenesis (fats/proteins to simple sugars)
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If liver is unable to manufacture plasma proteins and inactive hormones (aldosterone, estrogen) what problems arise?
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decreases proteins cause fluid shifts and edema can occur (pleural effusions, ascites). Increased circulating levels of aldosterone cause sodium and water retention thus hypoK, Hypocalcemia and hypomag.
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Babinski's reflex
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sole of foot is hit, foot extends (not flexes). Can be sign of neuro damage (encephalopathy)
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steatorrhea
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excessive fat in stool (liver disease)
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Stage I encephalopathy
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mild confusion, decreased attention span, forgetful, irritabel, personality changes, EEG normal
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Stage II encephalopathy
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lethargy, confusion, apathy, tremor (liver flap), slowing of EEG,
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Stage III encephalopathy
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severe confusion, incomprehensible speech, hyperactive deep tendon reflexes, EEG abnormal (intubation usually required)
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Stage IV encephalopathy
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posturing/no response to stimuli, + Babinski's reflex, EEG abnormal
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drug for acetaminophen toxicity
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Mucomyst, administred within 24 hrs of acetaminophen
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LeVeen shunt
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uses positive abdominal pressure caused by the diaphragm descent during inspiration to open a intraperitoneal valve and shunt fluid from the peritoneum to the superior vena cava (for ascites)
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Denver shunt
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adds a SQ pump that can be compressed manually to irrigate the intraperitoneal tubing (relief of ascites)
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hyperammonemia and respirations
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causes respiratory alkalosis. At this point patient on ventilator d/t encephalopathy so make sure you control their respirations (paralysis)
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Why avoid LR in liver failure?
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liver converts lactate to bicarbonate, extra work for liver
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clinical indications of hepatorenal syndrome
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(renal failure d/t blood flow changes caused by liver failure) oliguria, low urine sodium, elevated BUN & creatinine
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azotemia
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a medical condition characterized by abnormally high levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood. It is largely related to insufficient filtering of blood by the kidneys
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neomycin
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(aminoglycoside) kills the bacteria that convert nitrogenous wastes to ammonia
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lactulose in liver disease
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bonds with ammonia by changing gut pH, which results in ammonia excretion. Changes gut flora to foster growth of non-ammonia forming bacteria.
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When do you allow/restrict dietary protein in liver failure?
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increase it in cirrhosis and liver failure, restrict it in hepatic encephalopathy
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mild acute pancreatitis
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edematous pancreas with little necrosis damage, hypovolemia may occur as a result of fluid leak into peritoneal cavity.
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severe acute pancreatitis
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extensive necrosis or pancreas and peripancreatic tissue and fat: erosion into blood vessels; hemorrhage occurs; SIRS usually too
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common causes of pancreatitis
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obstruction of common bile duct (gallstone = cholelesthiasis MOST common, post ERP), ETOH, drugs, 20% idiopathic
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how do we decrease release of and destruction by pancreatic enzymes during pancreatitis?
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NPO during acute phase, NGT suction decompress stomach if ileum, drugs that decrease this Octreotide SQ & histamine receptor antagonists, keep environment free of food odors
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System for grading pancreatitis from CT findings
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Grade A = normal
Grade B = focal/diffuse enlargement Grade C = Mild peripancreatic inflammatory changes Grade D = fluid collection in a single location Grade E = multiple fluid collections or gas within pancreas or peripancreatic inflammation |
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What causes hypocalcemia in pancreatitis?
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inflammatory process causes necrosis of fat in pancreas and exudates with high albumin content leading to hypoalbuminemia and ascites: fat necrosis results in precipitation of calcium, leading to hypocalcemia
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pancreatic fistula
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caused by pancreatitis pancreas communicating with skin
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intestinal infarction
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necrosis of the intestinal wall resulting from ischemia
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intestinal obstruction (2 types)
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failure of the intestinal contents to progress forward through bowel lumen. Function (loss of peristalsis aka paralytic ileus) or structural (mechanical obstruction)
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2 types of structural intestinal obstructions (mechanical)
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simple = luminal obstruction without compromise of blood supply.
strangulated = luminal obstruction with compromise of blood supply. |
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intestinal performation
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penetration of the lumen of intestine with resultant spillage of intestinal contents into peritoneal cavity
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causes of intestinal infarction
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emboli, hypercoagulability, vascular disease, surgical procedures involving aortic clamping, vasopressors, strangulated intestinal obstruction, infection, cirrhosis
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most common type of intestinal obstruction and which type is it?
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paralytic ileus (functional obstruction)
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what things can cause functional intestinal obstruction?
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(this is loss of peristalsis). abdominal surgery, hypoK, pancreatitis, peritonitis, severe trauma, PNM, spinal cord injury, narcotics, sepsis etc......
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What can cause peritonitis in bowel infarction?
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prolonged ischemia increases the permeability of the bowel and edema of the intestinal wall. Normal bowel flora (e coli) may penetrate the bowel wall, causing peritonitis
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obstruction specific to small intestine (unique problems)
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increased intraabdominal pressure puts pressure on diaphragm, causing atelectatic changes and possibly PNM. Reverse peristalsis occurs N&V early
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obstruction specifict to large intestines (unique problems)
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distention of bowel eventually causes perforation with leakage of intestinal bacteria into peritoneal cavity (peritonitis and sepsis). Vomiting is late symptom.
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flat plate of abdomen xray shows what in obstruction
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dilated loops of gas filled bowels
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bed rest activity to encourage obstruction/infarction/perforation patients to do
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knee flexion to relax abdominal muscles
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Biggest concern if bowel obstruction is present
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preventing perforation of bowel!
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drugs that enhance GI motility in partial intestinal obstruction
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erythromicin, Reglan, Octreotide
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Purpose of nasointestinal tube
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decompresses bowel, ONLY use if obstruction is reversible or patient can't have surgery (so NOT in paralytic ileus or complete intestinal obstruction). This tube moves through the GI tract by peristalsis. Once tube at final position (confirmed on X-ray) tape in place. Irrigate tube as required.
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how to prevent bowel performation in intestinal obstruction
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NPO, NGT low suction, drugs, maybe nasointestinal tube, rectal tube (reduce trapped air), therapeutic colonoscopy
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When is surgery indicated in intestinal performation/obstruction/infarction?
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vascular obstruction, complete bowel obstruction or bowel performation
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surgical procedure for infarction of bowel
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exploratory lap and embolectomy and/or arterial reconstruction with resection of irreparably damaged bowel
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surgical procedure for obstruction of bowel (when indicated)
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correction of cause:if adhesion, laparoscopic adhesiolysis, herniorrhaphy for hernia reduction, bowel resection for tumors/malignant lesions
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brachytherapy in colon cancer
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the placement of radioactive seeds in the area where the tumor was removed
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abdominal trauma
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trauma that occurs between the nipple line and mid thigh
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What abdominal organ is most often affected by penetrating trauma?
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liver
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what abdominal organ(s) is most often affected by blunt trauma? (crushing)
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spleen and then pancreas as well
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Kehr's sign
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left shoulder pain indicative of splenic rupture caused by blood below diaphragm that irritates the phrenic nerve
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Rovsing sign
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pain in RLQ with plapation of LLQ indicates peritoneal irritation
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Coopernail's sign
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ecchymosis of scrotum or labia indicative of fractured pelvis
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Ballance's sign
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resonance over right flank with patient on left side indicates ruptured spleen
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explain the FAST (focused abdominal sonography for trauma) study
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detects fluid or blood in the pericardium, abdomen, or pelvis and allows visualization of the spleen and liver (although test can't reliably identify injury to the intraabdominal organs, need CT for this, it can accurately predict the need for laparotomy in trauma patients)
BEDSIDE ULTRASOUND |
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laparotomy
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large incision made through abdominal wall to gain access to abdominal cavity
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DPL (diagnostic peritoneal lavage). Explain study.
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can assess for intraabdominal bleeding, though FAST ultrasound is usually the preferred method. Put 1L NS into peritoneal catheter over 15 minutes (if peritoneal catheter fills with blood once inserted, go straight to ex. lap). Move patient side to side, drain fluid. Send for analysis. Considered positive if newsprint can't be read through lavage.
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What are the limitations of DPL study in terms of assessing for abdominal injuries
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does not detect diaphragmatic or retroperitoneal injuries
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Whipple procedure
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removal of lower stomach and duodenum w/ anastomosis of the remaining stomach to the jejunum with partial/total pancreatectomy and possible splenectomy
(done in cancer of pancreas or post necrotic tissues of pancreatitis) |
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esophagogastrostomy
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removal of all or a portion of esophagus possibly with a portion of stomach, with anastomosis to the remaining portion of stomach
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esophagoenterostomy
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removal of all or a portion of the esophagus along with replacement with a segment of the colon
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total colectomy and ileostomy
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removal of the entire large intestine and the formation of a stoma at the end of the ileum
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abdominoperineal resection
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removal of the anus, rectum and sigmoid colon with creation of a permanent colostomy
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2 restrictive procedures
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2 restrictive = vertical banded gastroplasty and gastric banding
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2 malabsorptive procedures for morbid obesity
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intestinal bypass and Roux-Y gastric bypass
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vertical banded gastroplasty
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stomach "stapled" smaller, eat less food. Dangerous operation, done less now.
(restrictive procedure for obesity) |
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gastric banding
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placement of a prosthetic device around the gastric cardia to limit oral intake
(restrictive procedure for obesity) |
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intestinal bypass
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(malabsorptive procedure) formation of an anastomosis between the upper small intestine and the lower small intestine or large intestine. High complication rate.
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Roux-Y gastric bypass
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combines gastric restriction and malabsorption; in addition to creating a gastric pouch the small bowel is resected so that upper jejunum is connected to pouch and lower jejunum is anastomosed to the biliopancreatic limb (digestive juices do not come into small bowel until the lower jejunum so absoroption is decreased).
Laparoscopic |
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Post GI surgery, what can you expect as fluid mobilizes 2nd/3rd day post op
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increased u/o
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Why don't you want to use wound packing soaked in betadine?
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toxic to fibroblasts, decreases epitheliazation, increases risk infection, iodine may be absorbed and cause nephrotoxicity
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drainage from ileostomy is _______
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watery, excoriating and continuous
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drainage from ascending colostomy is _______
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watery or semi solid, excoriating and continuous
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drainage from transverse colostomy is ________
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pastelike or semisolid and occurs at unpredictable intervals (maybe 3-5 days post op before any drainage)
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drainage from descending or sigmoid colonscopy is _____
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formed stools that may be at predictable intervals (i.e. after breakfast), may be 3-5 days post op until stool.
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what color should stoma be?
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same color as oral mucosa
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