Pre Anaesthetic Evaluation

for Endoscopic Procedure

Dr. Sarojini Bobde maam
Dr. Kalyani
 Introduction
Over past many years there is enormous growth in number of gastrointestinal
endoscopic procedure in view of

*Aging of patient

*Increased awareness of cancer

*Screening scopies

Increasingly complex procedures and increased case volume, broaden scope of

challenges anesthesiologist face in caring of patient

For deciding choice of anesthesia, it requires thorough understanding of

comorbidities and pre procedure evaluation
Aim

It is important to evaluate patient preoperatively

● To get knowledge of disease process

● To correct fluid and electrolyte disorders
● To optimize nutritional status
● To correct underlying abnormalities
● To decide plan of anaesthesia
Functions of Liver
Liver is responsible for numerous hemostatic and synthetic processes vital for
survival,

1. Metabolic
2. Synthetic
3. Immunological
4. Regenerative
5. Homeostatic
Symptoms and Physical assessment
Patient with liver diseases presents with symptoms like,

● Fatigue
● Weight loss
● Pruritus
● Bloating pain, dark urine, pale stool

While doing physical assessment look for icterus, ascites, pleural effusion,
peripheral edema, altered mental status, hepatosplenomegaly, Spider nevi
Baseline Lab Investigations
All investigations done by surgeon should be screened for additional
information pertinent to disease

● CBC - Due to malabsorption and pathology in GI tract hemoglobin level can

be on lower side, WBC count changes according infection,
Thrombocytopenia can also be seen in portal hypertension, splenomegaly
● Serum electrolytes- dyselectrolytemia can be seen because of diarrhea and
intestinal pathology
● LFT - With this we can measure dysfunction of hepatocytes or biliary
system(through bilirubin level) and synthetic function(Albumin and
coagulation factors) too
● Bilirubin- It is breakdown product of hemoglobin and myoglobin, unconjugated
bilirubin converted into conjugated via liver and excreted into bile
Increased level of unconjugated bilirubin seen in; hemolytic process, breakdown of
hematoma, portal hypertension
While conjugated will increase in biliary obstruction, impaired biliary excretion of
bilirubin like in sepsis and hepatic dysfunction
● Aminotransferase- ALT & AST important for hepatic gluconeogenesis, ALT is highly
specific to liver while AST can be extrahepatic.
AST/ALT ratio <1 seen in non alcoholic steatohepatitis while 2-4 seen in
alcoholic liver disease
● ALP (Alkaline Phosphatase)- Lack specificity for liver disease because it’s
isoenzyme present in plasma membrane throughout body,

it has t1/2 life of 1 week so can be seen elevated after bilirubin obstruction
resolution also

● Albumin- Abundant protein secreted by liver, diminished level indicates

reduction in synthetic capacity of liver
● INR- It evaluate synthetic pathway of coagulation

Depend on factor IIV and vit K dependent clotting factor produced by liver
Various pathophysiological conditions in GI system
Liver diseases affect Hepatocytes with or without biliary system, which will
further affect protein synthesis, bile regulation, metabolism of toxins or drugs.
● Common liver diseases- Hepatitis(Viral, Drug induced, Autoimmune)
Obstructive disorders (choledocholithiasis), Cirrhosis,
Liver Failure, Sclerosing Cholangitis
● Other basic GI tract related diseases-
Acute Pancreatitis
Inflammatory bowel diseases
Carcinoid tumour
There are various endoscopic procedures which require specific level
of anesthesia depending on invasiveness, stimulation by procedure and
patient factors
Procedures like- a) ERCP
b) OGD Scopy
c) Sigmoidoscopy/ Colonoscopy
A. ERCP (Endoscopic Retrograde Cholangiopancreaticography)
● Fluoroscopic examination of biliary and pancreatic duct endoscopically.
Many patient who require this includes diagnosis like cholangitis, pancreatitis
● Clinical features will include symptoms like severe pain, Difficulty in
swallowing, bleeding etc
● Indications-
Diagnostic- Used when suspected person’s bile/pancreatic duct may be
Narrowed Due to Tumor, Gallstone, Inflammation due to trauma,

dysfunction of Valves in duct & when there is biliary or pancreatic stasis

Therapeutic - For Sphincterotomy

Stone removal

Stent placement

Balloon dilatation

Tissue sampling
1. Hepatitis-

Its inflammatory disease of liver parenchyma

Caused by drugs(statins, acetaminophen, isoniazid) alcohol, viruses

(Various types like A, B, C, D, E)

It may occur with minimal symptoms can get complicated due to malaise and
jaundice, but can also progress to chronic liver disease, cirrhosis and HCC
TABLE
2. Obstructive Disorder- (Acute Cholecystitis, Choledocholithiasis)

In acute cholecystitis; gallbladder or biliary tract(cystic duct or common bile duct)

stone produces acute inflammation of gallbladder

Clinical features- Nausea, fever,tenderness,abdominal pain(that begins in mid

gastrium moves toward right upper quadrant called as biliary colic)

Serum bilirubin level and ALP level increases

These patient may land up into septic shock, peritonitis, coagulopathy.

While doing ERCP in such cases, insufflation of abdominal

cavity(Pneumoperitoneum) results into increase in intra abdominal pressure
interfere with adequacy of ventilation and venous return also
3. Cirrhosis

Progressive parenchymal liver damage and co-existent tissue regeneration disrupt

in normal hepatic architecture lead to nodular transformation.

Clinical features- Fatigue, malaise, jaundice later on may develop into

gynecomastia, spider angiomata, ascites.

Lab investigations will show- Elevated bilirubin, Aminotransferase, ALP, INR

Thrombocytopenia

Decreased Albumin level

Hypoglycemia
Other features-
● Portal Hypertension- With fibrotic degeneration of liver in cirrhosis and
increase in resistance to intrahepatic blood flow; portal vein flow decreases
which develops portal hypertension
● Ascites and peritonitis- In cirrhosis; portal hypertension,
hypoalbuminemia,sodium water retention bacterial peritonitis can occur
● Gastroesophageal Varices- Portal hypertension interferes with splanchnic
venous blood flow, submucosal vein become dialated allows increased flow in
azygos vein

Patient with massive bleed will require Endotracheal intubation to protect

airway
● Hepatic Encephalopathy- Neuropsychiatric changes appear with declining
liver function, Portosystemic shunting may exacerbate hepatic
encephalopathy by allowing ammonia and other byproduct to pass hepatic
clearance.
● Hepatopulmonary Syndrome- Cirrhosis leading to peripheral vasodilation lead
to intrapulmonary shunting and ventilation- perfusion mismatch
● Coagulopathy - Liver synthesizes numerous anticoagulant proteins and
antifibrinolytic plasminogen activator inhibitor, in cirrhosis disturbance in clot
formation and dissolution occurs.
4. Acute Liver failure-

Rapid development of severe liver damage with impaired synthetic function and
encephalopathy

It can develop within 4 weeks from 1st day of appearance of jaundice, if develops
within 8 days called as fulminant hepatic failure.

Coagulopathy, Renal failure, Cardiorespiratory complication, metabolic

derangements are frequent with this

Patient with liver diseases have diminished physiological reserve with which to
respond surgical stress as a result increased risk of bleeding, infection, hepatic
decompensation occur
Child Pugh Classification- To predict surgical mortality in cirrhotic patient
MELD Score- (Model for end stage stage liver)

6.43+(3.78 x log bilirubin) + (11.2 x log INR) + (9.57 x log creatinine)

If its more than 40 chances of mortality in 90 days will be 71.3%

5. Acute Pancreatitis- Pancreatic inflammation

Pancreas has various protective mechanisms like, packing of protease in

precursor form, synthesis of protease inhibitor, low intrapancreatic conc of calcium
decreasing trypsin activity, loss of this lead to autodigestion and pancreatitis.

Clinical features- Abdominal pain, nausea, vomiting, Dyspnea may reflect

presence of pleural effusion and ascites, shock may occur due to systemic effect
of pancreatic enzymes in general circulation, hypotension, release of kinin

ERCP is effective in traumatic pancreatitis, gallstone pancreatitis

It is important to identify patient at risk of dying from disease- Ranson score

Ranson Score-
Ranson criteria help to identify risk of dying from disease

● 0 to 2 - mortality less than 5%

● 3 to 4 - mortality 20%
● 5 to 6 - mortality 40%
● 7 to 9 - mortality of 100%

Complications-

● Hypotension- Due to large volume of fluid in peripancreatic space,

hemorrhage, systemic vasodilation
● Arterial Hypoxia- presents in early stage
● GI hemorrhage coagulation profile may occur
B . EGD(Esophagogastroduodenoscopy)

Indication- To treat conditions like bleeding ulcer, varices or narrowed

esophagus
Examination of upper GI tract using endoscope
Most difficult part to pass the scope is post cricopharyngeus muscle level
Clinical features will be difficulty in swallowing, weight loss, acid reflux,
mass in abdomen, hemoptysis, hematemesis, persistent vomiting
C. Sigmoidoscopy / colonoscopy
Its diagnostic or therapeutic examination of lower GI tract

Clinical features will be abdominal pain, diarrhoea, rectal bleeding, iron

deficiency anemia, weight loss

Indications- Screening colorectal cancer, evaluating unexplained changes

in bowel habits, treating inflammatory bowel diseases, removing polyp
1. Carcinoid Tumor-
Slow growing neuroendocrine tumor arising from Enterochromaffin cell;
disseminated throughout GI and bronchopulmonary segment

Within GI tract tumour arising from ileocecal region have highest incidence of
metastasis

These tumor cells secretes 5 HT (5 Hydroxy tryptamine) along with this other
neurohumoral agents also secreted like, dopamine, histamine, Substance P,
Neurotensin, Somatostatin
Clinical features will be like- Pain in abdomen, bloating, nausea, vomiting,
tachycardia, shortness of breath, wheezing, heart valve diseases
Effects on Various systems-
A) CVS- Positive chronotropic and inotropic myocardial effect due to release
of noradrenaline
Substance released from tumor causes fibrosis of heart can lead to
Pulmonic stenosis and tricuspid insufficiency
Due to vasoactive substances there will be intraoperative hypotension
B) RS- Rarely causes bronchoconstriction
C) GI tract- Increased Secretory function can cause intraoperatively

hypersecretion of gastric juice, increased motility,

Diagnosis- 1. Blood test- Serotonin level (Normal- 39 ng/l)

2. Urine analysis- 5 HIAA level in 24 hr sample

3. Serum Neuron, specific enolase and pancreastatin (in poor prog)

Treatment- Somatostatin Analogue (Octreotide, Lanreotide) has inhibitory action

On peptic effect on receptor cells

In patient with severe hypotension which is uncontrolled,

Vasopressin is drug of choice

2. Inflammatory Bowel Diseases-

In ulcerative colitis there is continuous inflammation of colonic mucosa starting

at rectum

In Crohn's disease there is intermittent healthy area in mucosa with thickening of

colon wall (cobblestone appearance of surface)

Patient may have deficiency in iron, folic acid, vit12, coagulation related disorder
due to malabsorption
THANK YOU