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Esophageal Varices

QuestionAnswer
The blood vessels that line the intestines and stomach all join together into the major route into the liver which is what? The Portal Vein
What happens to the blood flow of the liver when there is scar tissue in the liver? It gets obstructed and it backs up.
When we have congestion in the liver what is this condition called? Portal Hypertension
An obstruction of the flow of portal venous blood flow. Portal Hypertension
What does portal hypertension do the blood pressure? It creates an increase in blood pressure.
Where does the blood flow to when there is congestion caused by portal hypertension? The blood goes to the path of least resistance, low pressure veins that run along the lower portion of the esophagus, the upper portion of the stomach, and they can even back up to the rectum.
The underlying pathophysiologic problem of esophageal varices is: Portal Hypertension
What are the two big complications that portal hypertension creates with liver disease? Esophageal varices and ascites.
Fluid in the abdomen is called: Ascites
When gastric secretions erode the low pressure blood vessels, what are these blood vessels referred to as? Esophageal Varices
Patients with esophageal varices have a tendency for what? Bleeding
Extremely dilated sub-mucosal veins in the lower esophagus. Usually a consequence of portal hypertension. Esophageal Varices
Portal Hypertension is commonly due to what condition of the liver? Cirrhosis
How much blood goes through your liver? 1500 mL/min all the blood in your body goes through your liver every 2 minutes.
What happens if the flow of blood through the liver is broken? The patient could have a massive hemorrhage.
As a nurse if you have a patient who is vomiting profuse amounts of blood, what is your #1 priority? Maintain a patent airway whether it is by positioning a patient on the side, or suctioning.
After maintaining a patent airway in the patient vomiting profuse amounts of blood, what will your next priority be? Assess for signs and symptoms of hypovolemic shock.
If a patient is lucky enough to survive the initial bleed caused by a massive hemorrhage, what condition might they develop? Anemia
As a nurse can we treat shock independently? No, it is a collaborative problem.
When the blood from a massive bleed is just hanging around in the stomach and gut, what happens to it and why is this dangerous? It breaks down into protein and protein gives us ammonia. Too much ammonia could cause hepatic encephalopathy.
When your body suffers massive blood loss, how does it compensate? It shunts blood to the main organs which are the heart, lungs and brain. NOT THE KIDNEYS AND NOT THE LIVER!
What condition do patients go into if the blood is shunted away to the main organs after a massive blood loss? Hepato-Renal Failure
Rapid deterioration of kidney function in patients with cirrhosis or liver failure. Hepatorenal Syndrome
These tubes put pressure and suction on the blood vessels. They are used to apply pressure to the bleeding varices internally. Blakemore Tube
What is the nurses job in relation to the Blakemore tube? To check the balloons for leaks and apply K-Y jelly to the tubes before the physician inserts them.
A tube for esophageal varices that doesn't have an esophageal balloon and only has a gastric ballon is called a: Littman Tube
How do we verify placement of a Blakemore tube? By auscultation. You inject air through the port and then you listen 2 fingers below the xyphoid for a swish of air.
When do we inflate the balloons of the Blakemore tube? After verifying placement by ausculatation.
Why do we inflate the balloons of the Blakemore tube? To apply pressure to the bleeding vessels.
How much air do we put into the stomach port (gastric) of the Blakemore tube? 150-300cc's of air
How much air do we put into the esophageal balloon and how do we do this? It is pumped with air from the pump part of the sphygmomanometer. It is pumped up to around 25-45 mmHg.
Most varices are located where? Along the lower portion of the esophagus and the upper portion of the stomach.
Why don't we put alot of pressure in the esophageal balloon? Because of where the varices are located and to allow us to put pressure on the lower portion of the esophagus and the upper portion of the stomach.
After both balloons of the Blakemore tube are inflated, how do we apply even more pressure? By pulling on it with traction. Using an IV pole and looping it over and using weights or an IV bag to stretch it out and keep it taught.
What are the 3 things a nurse needs to do when a patient has a Blakemore tube? You want to use suction to remove the pooling of saliva in the patients mouth, you need to deflate the balloon Q8 hours for 5 minutes and then re-inflate.
Why can't patients with a Blakemore tube swallow their saliva? Because the esophagus is blocked off.
What is the optimal amount of time for a Blakemore tube to stay in? 48 hours
What is the maximun amount of time that Blakemore tubes stay in? Up to 4 days.
What are the two potential complications of a Blakemore tube? Respiratory distress and esophageal rupture.
What do you do if there are any signs of respiratory distress in a patient with a Blakemore tube? Cut and pull!
What could cause respiratory distress in a patient with a Blakemore tube? If one of the balloons sprung a leak and it crept up over the airway, it could cause an airway obstruction.
What would indicate esophageal rupture in a patient with a Blakemore tube? Sudden complaints of mid-epigastric or mid upper back pain accompanied by signs of shock.
What happens if a patient has an esophageal rupture. It is a medical emergency and they have to go into surgery right away to repair it.
Varices are visualized by endoscope and then through the scope a needle is inserted and a chemical cartery agent is injected. Injection Sclerotherapy
This procedure zaps the bleeders and in about 2-5 minutes bleeding stops and the varices get kind of a white patchy look. Injection Sclerotherapy
What does injection sclerotherapy accomplish? It burns the end of the vessel so that it won't bleed.
What are the nursing implications for a patient who undergoes injection sclerotherapy? Listen to lung sounds for pleural effusion or pneumothorax caused by puncture of the esophagus.
When little rubber bands are tied around the varices, what is this procedure called? Banding or endoscopic ligation.
In this procedure, the scope has suction and it sucks the varices into the scope, the doctor then shoots a little rubber band around it and then it sucks it off. Banding or endoscopic ligation.
This procedure for varices is also used to remove hemorrhoids. Banding or endoscopic ligation.
What kind of treatments are there for esophageal varices? You can use the Blakemore, endoscopic procedures, and or medications.
What two endoscopic procedures are used to treat esophageal varices. Injection sclerotherapy and banding (endoscopic ligation).
What effects does Pitressin (vasopressin) have on the body? It is a potent vasoconstrictor. It constricts everything in the body.
What patients should not get Pitressin (vasopressin)? Cardiac patients, CAD patients, or patients with chest pain.
How is Pitressin (vasopressin) administered? IV Drip
Pitressin (vasopressin) is a deritive of what? ADH
If you are administering Pitressin (vasopressin) and the patient complains of chest pain, what do you do? You stop the IV drip immediately!
What precautionary action do some facilities take when they are administering Pitressin (vasopressin)? They administer it with IV nitroglycerin to dilate the coronary arteries and counter act the effects of Pitressin (vasopressin) on the heart. This is done for patients in which there has not been a previous diagnosis of any heart disease.
What are the 3 main things to remember about the use of Pitressin (vasopressin)? It is contraindicated with CAD. Stop it with chest pain. It is given with prophylactic IV Nitroglycerin.
What kind of a medication is Sandostatin (octreotide)? It is a growth hormone inhibitor.
What does Sandostatin (octreotide) do? It decreases blood flow to the gut.
Why would Sandostatin (octreotide) be used with patients that have portal hypertension? It decreases the blood flow and in turn helps to decrease the portal hypertension which is caused by obstruction of the blood flow to the liver.
If you are trying to decrease the blood pressure in patients with portal hypertension and slow it down, what medication would you administer? Sandostatin (octreotide)
When would Sandostatin (octreotide) be administered by IV? To treat portal hypertension.
When would Sandostatin (octreotide) be administered SC? To patients who have had gastrointestinal surgery because they want to decrease a lot of edema or swelling in the area.
Are pitressin and sandostatin used during an acute or a chronic bleed? During an acute bleed.
What kind of a medication is Inderol (propanolol)? It is a beta blocker.
What does Inderol (propanolol) do? It reduces HR, CO, BP and helps to decrease portal hypertension. It will decrease the pressure in the portal venous system.
Why don't we want patients with portal hypertension straining to have their BM's? Because it would cause intra-abdominal pressure and they would run the risk of bleeding.
What are the 5 medications that could be used to treat a massive bleed caused by esophageal varices. Pitressin, sandostatin, inderol, stool softeners, and carafate.
What is Carafate? It is a mucosal barrier fortifier. It is a paste that adheres to the mucosa and acts as a temporary paint.
Initially what medications will be used to treat a patient who is having a massive bleed caused by esophageal varices? Pitressin (vasopressin) or Sandostatin (octreotide)or they may use both.
If a patient survives a massive bleed caused by esophageal varices, what medications will be used to try to prevent reoccurrence of the massive bleed? Inderol (propanolol), stool softeners and carafate.
What does TIPS stand for? Transjugular Intrahepatic Portosystemic Shunt
In this procedure a guide wire is passed down through the jugular vein, then down into the vena cava, then down into the liver, then down into the portal vein, and then down into the hepatic vein. TIPS
Once the guide wire in a TIPS procedure is in the hepatic vein, what is inserted? A balloon is inserted and a stent is put in to keep the balloon from collapsing.
This procedure is like an internal bypass inside the liver. TIPS
What happens after TIPS? The pressure has been decreased, so the varices where there was greater pressure are going to decrease and the blood is going to flow back into the liver through the portal vein through this new route.
Why doesn't TIPS disqualify a patient for a liver transplant? Because it is all inside.
If there is no other option what procedure may a doctor try to buy time for patient suffering from portal hypertension? Portacaval Shunt
What is a portacaval shunt? When the portal vein is disconnected from the liver an attached to the vena cava.
Why is it not that good of an idea to do the portacaval shunt? Because the blood will bypass the liver and all of the metabolic functions, filtering, and detoxifying the liver is supposed to do don't get done.
If a patient has a portacaval shunt what happens to their eligibility for a liver transplant? They are no longer eligible. This surgery is basically a last ditch effort when nothing else works.
Why would a patient have an altered consciousness if they are experiencing a massive bleed from esophageal varices? Because of the ammonia levels.
Why would sedatives and hypnotics not be used in the case of a massive bleed caused by esophageal varices? There may be the concern of not wanting to impair the liver anymore.
What is caput medusae? Dilated blood vessels on the abdominal wall around the umbilicus. It looks like the head of a snake.
What is palmar erythema? When you have a buildup of estrogen in the body, the liver doesn't break it down. Estrogen levels build up in the body and you end up with red palms.
Are large or small varices more likely to bleed? Large varices are more likely to bleed.
What percentage of variceal hemorrhages are esophageal varices responsible for? What percentage are gastric varices responsible for? 80% - Esophageal Varices 20% - Gastric Varices
What is the most life threatening complication of cirrhosis? Bleeding esophageal varices.
The factors that lead to irritation and ulceration of esophageal varices are: Alcohol ingestion, swallowing poorly masticated food, ingestion of course foods, acid regurgitation from the stomach, and increased intra-abdominal pressure.
What things could cause increased abdominal pressure? Nausea, vomiting, straining to stool, coughing, sneezing, and lifting heavy objects.
Risk factors for bleeding with esophageal varices are: Variceal size, decreased wall thickness, and the degree of liver dysfunction.
Patients with esophageal varices should avoid: Alcohol, aspirin, irritating foods coughing, and upper respiratory infections.
If a Blakemore tube had 3 lumens what would they be used for? One for the gastric balloon, one for the esophageal balloon, and one for gastric aspiration.
This last ditch effort is used more after a second bleeding episode than after an initial bleed. Portacaval shunt and other shunting procedures.
What kind of cells do the Islets of Langerhans secrete? Alpha cells, Beta cells, delta cells, and F cells.
What do Alpha cells do? Alpha cells produce and secrete glucagon.
What do Beta cells do? Beta cells produce and secrete insulin.
What do Delta cells do? Delta cells produce and secrete somatostatin.
What do F cells do? F cells secrete pancreatic polypeptide.