GI

Question 1

What do diffuse esophageal spasms mimic?

Answer 1

• Mimics angina
  
  • if they come in for a scope for this, they have probably already seen a cardiologist
• most often occur in elderly

Question 2

Upper Endoscopy:

sedation goal?

type of anesthesia?

What do you need to have?

Answer 2

• Goal: to avoid apnea
  
  • avoid oversedation
  • have entire airway setup ready just in case
• TIVA- propofol
  
  • maybe with fentanyl and/or lidocaine to decrease cough/gag with scope
• Bite block, before sedation
• Ambu bag
• airway setup

Question 3

A little about how this works…

Answer 3

• Pt will be positioned on side
• Surgeon will flood stomach with irrigation while scoping
• Will suction stomach out before removing scope
• both irrigation and suction happen through this scope wand thingie

Question 4

What does ERCP stand for?

What is it used for?

Answer 4

• Endoscopic Retrograde Cholangio-pancreatography
• used to diagnose and treat conditions of the bile ducts
  
  • gallstones
  • inflammatory strictures
  • leaks (from trauma and surgery)
  • cancer

Question 5

How does an ERCP “work?”

Duration of procedure?

Type of anesthesia?

Concern?

Answer 5

• ERCP combines the use of X-rays and an endoscope
• duration is 30 min to 2 hours
• TIVA if short case, GA if case is more complicated
• Concern for aspiration, extubate wide awake with full airway protective reflexes back.

Question 6

What is chronic peptic esophagitis?

surgery?

Answer 6

• “heartburn”
• retrosternal discomfort relieved by antacids
• if persistant and severe, may require surgery
  
  • Nissen fundoplication

Question 7

What are some anesthetic considerations for a pt with chronic peptic esophagitis?

Answer 7

• Pretreatment with aspiration/RSI meds
• antibiotics
• NG or OG inserted for surgery
  
  • keep to gravity
  • use NG if it will need to remain post-op
• N/V post op- zofran
• pain management

Question 8

How can the Nissen fundoplication be done?

Anesthesia type?

Answer 8

• Open or laparoscopic
• Laparoscopic is more commone
  
  • 5 small incisions
  • one for laparoscope, the other 4 to retract and manipulate
• General anesthesia

Question 9

What is the Roux en y surgery?

Answer 9

• bypass procedure that creates a stomach pouch out of a small portion of the stomach and attaches it directly to the small intestine, bypassing a large part of the stomach and duodenum
  
  • laparoscopic most common

Question 10

What should you consider with an obese patient?

Answer 10

• Positioning- ramping for intubation
• airway may be difficult
• RSI

Question 11

Anesthesia considerations for Hiatal hernia?

Answer 11

• RSI- premeds
• implications depend on severity of the signs and symptoms
  
  • Ex. does the patient sleep sitting up?
• awake extubation
• OG

Question 12

Anesthesia considerations for achalasia?

Answer 12

• Risk of aspiration
  
  • pre-induction decompression
  • may place NG to suction

Question 13

What is peptic ulcer disease?

Signs and symptoms?

Answer 13

• Mucosal alteration of the esophagus, stomach or duodenum due to increased gastrin and HCl production
• S/S
  
  • midepigastric pain, relieved by food or antacids
  • hemorrhage resulting in chronic anemia
  • Gastric outlet obstruction

Question 14

What is gastric outlet syndrome?

Answer 14

• obstruction at the pyloris exiting stomach
• If pt retains >300 ml 30 minutes after drinking 750 ml of saline

Question 15

What are the treatments for PUD?

What are the anesthetic implications of these treatments?

Answer 15

• H-2 antagonists and anticholinergics are used to treat PUD more than surgery
  
  • pyloroplasty and/or vagotomy
• Anesthetic implications:
  
  • H-2 antagonists may inhibit CYP450
  • nasogastric suctioning
  • RSI

Question 16

What is UC?

Answer 16

• inflammation of colonic mucosa
  
  • rectum and distal colon
• most common in women age 25-45 and Jewish origin
• diarrhea, cramping, abdominal pain
• low grade fever, fatigue, weight loss during exacerbations

Question 17

What is crohn’s disease?

What are some extracolonic features of this disease?

Answer 17

• Inflammation of all layers of the bowel
• leads to fistula development
• Extracolonic features
  
  • arthritis
  • calcium oxalate (renal and gallstones due to increased absorption of oxalate by the colon
  • decreased albumin-protein loss via diseased bowel

Question 18

What are the anesthetic considerations for Inflammatory bowel disease?

Answer 18

• Fluid and electrolyte management
• avoid nitrous oxide
• supplemental (stress dose) steroids may be indicated
• anticholinesterases increase intraluminal pressure
  
  • stay on lower end of dosing
  • try to get 3-4 twitches back before reversing

Question 19

What do carcinoid tumors cause?

what is the treatment?

Answer 19

• Carcinoid tumors secrete corticotropic hromones, GHRF, and cause cushing syndrome
• Carcinoid syndrome
  
  • cutaneous flushing
  • bronchospasm
  • hypotension
  • diarrhea
• treatment
  
  • somatostatin analogue octreotide
  • resection of tumor by surgery

Question 20

What are some anesthesia considerations for a patient with a carcinoid tumor?

Answer 20

• continue the octreotide
  
  • can interfere with insulin release; exacerbate diabetes
  • short half life, must be given continuously
  • binds to receptor sites on the tumor to decrease symptoms
• bronchospasm of carcinoid tumor can be resistant to treatment
  
  • Octreotide 100-200 mcg IV
  • histamine blockers and ipratropium
• avoid histamine releasing drugs
• avoid ketamine
• avoid catecholamines b/c they release seratonin
• Arterial line necessary d/t hemodynamic variables

Question 21

What are some concerns for acute and chronic pancreatitis?

Answer 21

• Acute
  
  • can have major organ involvement
    
    • ARDS
    • renal failure
    • GI hemorrhage
    • DIC
  • shock- hypovolemia seen even in mild pancreatitis
    
    • fluid management very important
• Chronic
  
  • DM results from loss of endocrine function
  • malnutrition
  • opioids used for pain control

Question 22

Where does GI bleeding often originate from?

Answer 22

• Most often from the upper GI tract
• Bleeding from the lower GI tract (diverticulosis or tumor) accounts for 10-20%, commonly older patients

Question 23

What are some concerns regarding a patient with a GI bleed?

Answer 23

• low H&H
• hypotension and tachycardia (if blood loss exceeds 25% of total blood volume)
• must replace fluid volume, which may make anemia more obvious
• If esophageal vericies are bleeding, considered a full stomach

Question 24

Appendicitis:

symptoms

treatment/considerations

Answer 24

• Pain, N/V, dehydration, anorexia
  
  • preload with fluids
• Surgical treatment
  
  • may need RSI d/t slow digestion experienced by anybody in pain
  • antibiotics
  • avoid N2O

Question 25

Anesthesia considerations for bowel obstruction

Answer 25

* No metochlopramide- avoid agents that increase gastric motility * no N2O * RSI * Low albumin * require fluid volume replacement and electrolyte corrections * OGT to suction or gravity

Question 26

What are the anesthetic considerations for a patient with cholecystitis? type of surgery?

Answer 26

* Laparoscopic approach * insufflation will increase intra-abdominal pressure * insufflation can interfere with ventialtion; reverse trendelenberg position will help * impacts cardiovascular system and venous return * high intra-abdominal pressure causes concern for reflux (OG tube) * ETCO2 will increase- d/t ventilation changes and the insufflated CO2 into the abdomen * decrease TV, increase RR * Opioids can cause spincter of Oddi spasm whenever dealing with the gallbladder * Can improve with Naloxone, glucagon, or NTG * Don't actually use naloxone ever * NTG may be better for a diabetic patient