PERIOPERATIVE MANAGEMENT OF CO-MORBID CONDITIONS

The patient withgastrointestinal diseaseJohn McKenna

Chris Sadler

AbstractThe gastrointestinal system is responsible for digestion of food, absorp-

tion of nutrients and excretion of waste. It consists of the mouth, oesoph-

agus, stomach, small intestine, large intestine, liver, gall bladder and

pancreas. Many patients managed by surgical teams will suffer from

some form of gastrointestinal disease.

To aid with the management of these patients we will look at a logical,

systemic approach to the assessment of gastrointestinal disease and

common signs and symptoms found. We will discuss the investigation

of gastrointestinal disease and the common abnormalities found.

This article will then discuss in further detail the perioperative

management of some common gastrointestinal problems, namely fluid

therapy, nutrition, gastrointestinal bleeding, hepatic dysfunction, bowel

obstruction, inflammatory bowel disease and pancreatitis.

Keywords Assessment; bleeding; fluid therapy; gastrointestinal;

inflammatory bowel disease; investigation; management; nutrition;

obstruction; pancreatitis; perioperative

Introduction

Many patients present to the surgical team with a primary

gastrointestinal complaint, or have coexisting gastrointestinal

problems that complicate their perioperative management. This

article will cover the clinical assessment and investigation of

these patients, and the management of some common gastroin-

testinal presentations.

Broadly, the function of the gastrointestinal system is to digest

and absorb nutrients to support the functions of the body. It is

also involved in excretion of waste from the body. Therefore

dysfunction of the gastrointestinal system can affect many of the

body’s organ systems.

Assessment of the patient with gastrointestinal disease

It is important to have a logical and systemic approach to

assessment.

Airway and breathing

� Check airway patency and look for soiling or obstruction,

especially from vomit and blood.

John McKenna MBBS FRCA is a Specialist Registrar in Anaesthetics at

Barts & The London School of Anaesthesia, London, UK. Conflicts of

interest: none declared.

Chris Sadler MBBS FRCA PhD is a Consultant Anaesthetist at Barts & The

London NHS Trust, London, UK. Conflicts of interest: none declared.

SURGERY 28:9 437

� Check that the patient is able to swallow as this could lead to

airway compromise.

� Examine the mouth. Poor dentition may reflect nutritional

status and oral infection is a potential source of sepsis.

� Examine the chest, and measure the respiratory rate and

peripheral oxygen saturation.

Any condition causing the airway to fill with fluid such as

vomiting or an upper gastrointestinal bleed can cause potential

airway compromise. Pulmonary aspiration may occur as

a consequence of reflux or vomiting. It may present early as

respiratory distress, or late as pneumonia if aspiration is silent.

Increased intra-abdominal pressure can cause splinting of the

diaphragm. This can lead to basal atelectasis and hypoxia

secondary to ventilation and perfusion mismatch. Deficiencies in

nutrition lead to muscular weakness that, if severe, can weaken

the muscles of respiration. Fluid shifts, as a consequence of

sepsis, liver dysfunction or nutritional status may lead to capil-

lary leak, ascites and pulmonary oedema.

Circulation

� Assess the cardiovascular system, with particular regard to

fluid status.

� Record blood pressure, heart rate, and capillary refill time.

Hypovolaemia can be due to either inadequate intake, distribu-

tion of fluid outside the vascular compartment, or excessive

losses. Cardiac conduction and contractility can be adversely

affected by nutritional deficiencies and electrolyte disturbances,

in particular hypokalaemia or hyperkalaemia. Anaemia may be

secondary to haemorrhage or dietary haematinic deficiency.

Abdominal compartment syndrome can lead to cardiovascular

collapse due to compression of the major abdominal blood

vessels. This may be seen postoperatively in an intensive therapy

unit (ITU) setting.

Neurological

� Basic assessment of conscious level e Alert, Verbal, Pain,

Unresponsive (AVPU) score or Glasgow Coma Scale (GCS) e

is necessary.

� A Mini Mental State Examination (MMSE) and a full neuro-

logical examination may aid diagnosis.

Both acute and chronic alcohol use lead to neurological symp-

toms, ranging from acute intoxication to delirium tremens in the

withdrawing patient. Dietary thiamine deficiency may produce

the WernickeeKorsakoff syndrome. Chronic liver disease causes

accumulation of toxic metabolites, leading to encephalopathy.

Gastrointestinal

� Full assessment from mouth to anus.

� Bodymass index (BMI)may indicatenutritional status (Table 1).

Excessive vomiting can be indicative of gastrointestinal

obstruction and should also raise suspicion of dehydration.

Constipation, diarrhoea and altered bowel habit are significant

symptoms and may be associated with massive fluid losses.

Obesity may be associated with obstructive sleep apnoea, dia-

betes, and ischaemic heart disease. Jaundice may be pre-hepatic

(e.g. haemolytic diseases), hepatic (e.g. hepatitis) or post-hepatic

(e.g. biliary obstruction) in origin. Jaundice can lead to brain

damage in neonates, and intense itching if secondary to biliary

obstruction.

� 2010 Published by Elsevier Ltd.

World Health Organization classification of BMI1

Classification Body mass index (kg/m2)

Underweight <18.50

Normal range 18.50e24.99

Overweight >25.00

Obese >30.00

Table 1

PERIOPERATIVE MANAGEMENT OF CO-MORBID CONDITIONS

Renal

� Assessment of fluid status is vital. Look for skin appearance,

turgor and cardiovascular parameters.

� Consider fluid balance monitoring. Oliguria is a good indi-

cator of a dehydrated patient. Dipstick the urine.

Dehydration cannot be overemphasized in these patients. Hypo-

volaemia leads to hypoperfusion of the kidneys, which can lead to

acute renal failure. Renal calculi can be formed or exacerbated by

dehydration. Patients with advanced hepatic disease can develop

hepatorenal syndrome. This is caused by renal vascular vaso-

constriction in response to hepatic mediated hypotension.

Infection and immunity

� Examine the patient for any signs of infection e fever,

rigours.

� Record temperature.

Investigations in patients with gastrointestinal disease (adap

Full blood count Guides transfusion requirements.

Characterize anaemia.

Aid diagnosis of sepsis.

Urea and electrolytes Vomiting can lead to loss of potassium, sod

Serum urea rises in an upper gastrointestin

Hypocalcaemia due to reduced dietary intak

Iatrogenic disturbances caused by inapprop

Coagulation Liver dysfunction causes a prolongation in p

due to reduced production of clotting facto

Liver function tests Aspartate transaminase (AST) and alanine t

Alkaline phosphatase (ALP) raised in choles

Gamma glutamyl transferase (gGT) is induce

Microbiology If infection is suspected, blood and stool cu

Viral markers are important in establishing

Electrocardiogram Conduction problems caused by electrolyte

Peaked T waves suggest hyperkalaemia.

Radiology Air under the diaphragm on a plain erect ch

Patterns of intestinal gas on abdominal film

Ultrasound provides excellent images of sol

and may be used to identify ascites.

Computed tomography is useful in intra-abd

Endoscopy May be diagnostic or therapeutic.

Table 2

SURGERY 28:9 438

Perforation of the gut can cause faecal peritonitis. Patients with

jaundiceor liverdysfunctionshouldbe investigated forviralhepatitis.

Food-borne infection leading to gastroenteritis is a common presen-

tation. Immune function can be compromised in malnutrition and

hepatic dysfunction.Bacterial translocationoccurswhen the integrity

of the gut is compromised. Gut flora can reach the bloodstream

causing a bacteraemia. Obesity is a risk factor for wound infection.

Investigations

Investigations are summarized in Table 2.

Arterial blood gas analysis provides information about

pulmonary gas exchange and acidebase status (Table 3).

Perioperative management of gastrointestinal problems

Fluid therapy

When a patient is kept ‘nil by mouth’ in preparation for surgery

or because of gastrointestinal disease, the clinician is responsible

for maintaining fluid balance. The approach to fluid therapy

should include clinical assessment of hydration, calculation of

fluid deficit, maintenance requirements, replacing ongoing los-

ses, and monitoring response to fluid therapy (Figure 1).

Maintenance fluid requirements should be based on body

weight (Table 4). Maintenance requirements in a 70 kg patient

are (1000 þ 500 þ 1250) 2750 ml/day.

Ongoing losses (e.g. haemorrhage, diarrhoea, vomiting and

third space loss) must be quantified and replaced. Evaporative

fluid losses during laparotomy may exceed 15 ml/kg/hour.

ted from Allman and Wilson2)

ium, chloride and hydrogen ions.

al bleed due to digestion of blood in the stomach.

e of calcium or vitamin D.

riate fluid therapy.

rothrombin time (PT) or activated partial thromboplastin time (APTT)

rs.

ransaminase (ALT) released when hepatocytes are damaged.

tasis.

d by certain drugs and, notably, ethyl alcohol.

ltures should be sent to identify a causative organism.

a cause for liver disease.

disturbances.

est X-ray is suggestive of intestinal perforation.

s can be used to diagnose bowel obstruction.

id intra-abdominal organs such as the liver and gall bladder,

ominal trauma and suspected intra-abdominal sepsis.

� 2010 Published by Elsevier Ltd.

Acidebase disturbances in gastrointestinal disease

Condition Acidebase disturbance Cause

Diarrhoea Metabolic acidosis Bicarbonate loss

Pancreatic fistulae Metabolic acidosis Bicarbonate loss

Acute alcohol

intoxication

Metabolic acidosis Toxins metabolized

to acids

Ileostomy Metabolic acidosis Bicarbonate loss

Pyloric stenosis Metabolic alkalosis Hydrogen ion loss

Excessive vomiting Metabolic alkalosis Hydrogen ion loss

Table 3

Fluid requirements according to patient weight

Weight Fluid requirement (ml/kg/day)

First 10 kg (i.e. 1e10 kg) 100

Second 10 kg (i.e. 11e20 kg) 50

Each kg >20 kg 25

Table 4

PERIOPERATIVE MANAGEMENT OF CO-MORBID CONDITIONS

Fluid therapy is a dynamic process and it is important to

monitor response to fluids administered. With an appropriate

response to fluid, tachycardia should settle, blood pressure will

normalize, urine output should be >0.5 ml/kg/hour and, if

available, a sustained rise in central venous pressure (0e8

mmHg). Serum urea and electrolytes should be monitored, as

disturbances are common. For example, overuse of 5% dextrose

can lead to hyponatraemia, and overuse of normal (0.9%) saline

can lead to a hyperchloraemic metabolic acidosis.

The choice of fluid remains the subject of debate. Fluid

therapy should target the fluid compartment (intravascular,

extracellular, intracellular) that is depleted (Table 5).

Nutritional support

Catabolism is the normal response to sepsis, trauma and surgery.

Catabolic patients have higher energy requirements than normal

patients, and need their nutritional intake supplemented

accordingly. While it is preferable to achieve these nutritional

requirements by oral intake of normal diet, alternatives to oral

nutrition may be required.

Enteral feeding is preferred to parenteral feeding as it is more

physiological, maintains enterocyte integrity and reduces bacte-

rial translocation from the gut to the bloodstream. If the oral

route is unavailable, for example due to high aspiration risk, feed

can be administered via a nasogastric tube (NGT). For longer

term enteral feeding a gastrostomy or jejunostomy can be sited.

Parenteral nutrition, via a central vein, is considered when

gastrointestinal motility or absorption is impaired. Parenteral

Percentage fluid loss Signs and symptoms

5% Thirst

Peripheral shutdownTachycardiaReduced skin turgorOliguria

10%Tachypnoea HypotensionConfusionAnuria

15%Life threatening

Clinical signs of fluid loss2

Figure 1

SURGERY 28:9 439

nutrition carries more risks than enteral nutrition, namely

metabolic disturbances, hyperlipidaemia, and deficiencies in

trace elements. The fluids used for parenteral nutrition are an

excellent culture medium and great care is required to prevent

septicaemia.

Gastrointestinal bleeding

Upper gastrointestinal haemorrhage can occur anywhere from

the pharynx to the ligament of Treitz. It is characterized by

haematemesis, coffee ground vomitus and malaena. Upper

gastrointestinal haemorrhage may be amenable to endoscopic

therapy. Certain lesions can be treated with sclerotherapy or

injection of adrenaline. Variceal lesions can be banded. Full

anaesthetic precautions and monitoring are required for endos-

copy under sedation. Pharmacological management includes

proton pump inhibitors, and octreotide and terlipressin to reduce

splanchnic perfusion.

Lower gastrointestinal haemorrhage can occur anywhere from

the ligament of Treitz to the anus and is characterized by malaena

or fresh blood per rectum. Lower gastrointestinal haemorrhage

can be caused by diverticular disease, colitis and malignancy.

Hepatic dysfunction

Hepatic failure can be acute or chronic, and unless absolutely

necessary, those with acute hepatic failure should have their

operation postponed due to an increase risk of mortality.

Common causes include infection (hepatitis A-E) and toxins

(alcohol, paracetamol). In addition to having altered drug

metabolism, patients with hepatic dysfunction are at increased

risk of coagulopathic haemorrhage, hypoglycaemia, infection

and encephalopathy (Table 6).

Gastrointestinal obstruction

Gastrointestinal obstruction may be mechanical (e.g. foreign

body, malignancy, adhesions, strictures) or functional (e.g.

ileus). These patients frequently present for emergency surgery if

obstruction is prolonged or the gut is ischaemic. The clinical

picture will give clues to the site of the obstruction. Oesophageal

obstruction presents with dysphagia, odynophagia, regurgitation,

malnutrition and dehydration. Small bowel obstruction presents

Choice of fluid

Compartment Fluid

Intravascular Colloid (gelatin, starch, albumin), blood

Extracellular Electrolyte crystalloid (saline, Hartmann’s)

Intracellular Dextrose 5%

Table 5

� 2010 Published by Elsevier Ltd.

ChildePugh Score3

Measurement 1 point 2 points 3 points

Bilirubin (mmol/litre) <34 34e50 >50

Albumin (g/litre) >35 28e35 >28

International

normalized ratio

<1.7 1.71e2.20 >2.20

Ascites None Mild Severe

Hepatic

encephalopathy

None Grades IeII (drowsy

0 disorientated)

Grades IIIeIV

(stupor 0 coma)

Class Points 2-year survival (%)

A 5e6 85

B 7e9 57

C 10e15 35

Table 6

Ranson criteria.4 Each category carries 1 point

On admission After 48 hours

Age >55 years Serum calcium <2 mmol/litre

Leukocyte count >16 � 109/litre Fall in

haematocrit

>10%

Serum glucose >11.1 mmol/litre Rise in urea >1.8 mmol/litre

AST >250 IU/litre Base deficit >4 mmol/litre

LDH >350 IU/litre Artrial pO2 <60 mmHg

Fluid

sequestration

>6000 ml

Score <2 3e4 4e6 7e8

Mortality (%) 2 15 40 100

AST, aspartate transaminase; LDH, lactate dehydrogenase.

Table 7

PERIOPERATIVE MANAGEMENT OF CO-MORBID CONDITIONS

with early vomiting and colicky central abdominal pain. In large

bowel obstruction, constipation and lower abdominal pain are

more prominent features.

The principal complications of gastrointestinal obstruction are

eventual perforation and peritonitis, malnutrition and impaired

fluid balance. Fluid can be lost in vomit, or sequestered into the

bowel lumen. Up to 6 litres of fluid can be lost into the bowel in

severe small bowel obstruction; therefore adequate fluid resus-

citation is essential. Patients with severe vomiting are at risk of

aspiration and significant hypokalaemia.

Inflammatory bowel disease

Ulcerative colitis is restricted to the gut mucosa and affects the

colon and anus. Crohn’s disease can occur anywhere from the

mouth to the anus and affects the whole gut wall. Patients

typically present with fever, vomiting, abdominal pain, diar-

rhoea, and rectal bleeding during an acute exacerbation.

Inflammatory bowel disease may be associated with arthropathy,

anaemia, primary sclerosing cholangitis, uveitis and a pro-

thrombotic tendency.

Non-surgical management includes general supportive

measures (fluids, analgesia, etc.) and immunosuppression with

corticosteroids, methotrexate and azathioprine. Immunosup-

pression places patients at increased risk of infection risk and

may mask the symptoms and signs of gastrointestinal perforation

and peritonitis. Long-term steroid therapy may cause Cushing’s

syndrome and Addisonian crisis following abrupt withdrawal.

Methotrexate can cause neutropenia and is teratogenic. Surgery

is restricted to patients who have failed to respond to medical

treatment and those who have developed complications, such as

stricture, perforation, haemorrhage, abscess or fistula.

SURGERY 28:9 440

Pancreatitis

The severity of acute pancreatitis can be assessed in a variety of

ways based on biochemical, haematological, clinical (Glasgow &

Ranson) and radiological (Balthazar) criteria. The purpose of

scoring is to predict mortality and morbidity (Table 7).

Conclusion

Patients with gastrointestinal disease can be challenging to

manage in the perioperative period. Thorough assessment and

attention to simple problems, such as fluid balance, nutrition and

analgesia can greatly improve patient outcome. A

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3 Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Tran-

section of the oesophagus for bleeding oesophageal varices. Br J Surg

1973; 60: 646e9.

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CROSS-REFERENCE

Peterson M, Thomas WEG. Gastrointestinal haemorrhage. Surgery 2008;

26: 113e9.

FURTHER READING

Rassam SS, Counsell DJ. Perioperative fluid therapy. BJA CEPD Rev 2005;

5: 161e5.

� 2010 Published by Elsevier Ltd.