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Digestive System Exam 2 > 21:00 min Clinical Manifestation and Screening of Liver Disease (Rudinsky In Class Feb 3rd) > Flashcards

21:00 min Clinical Manifestation and Screening of Liver Disease (Rudinsky In Class Feb 3rd) Flashcards

1
Q

Notes Card
SBA Testing:

A
  • 2 hr post-prandial SBA (PPSBA)
    • Stimulates EHC
    • Endogenous challenge test
  • Food considerations
    • protein and fat content (release CCK)
    • < 10 lbs … > 2 tsp
    • > 10 lbs … > 2 tbsp
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2
Q
  • Liver-specific function test
    • Portosystemic shunting
    • Severe hepatocellular dysfunction
    • Urea cycle abnormality

What test is this?

A

Blood Ammonia

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3
Q

The liver plays the single most important role in the detoxification/clearance of many different substances such as:

A
  • Drugs
  • Toxins
  • Hormones
  • Metabolites
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4
Q

Hepatic Drug Metabolism:
- Primary oxidation
- Enzymes of SER (microsomal)
- Usually inactivates drugs
- May convert active to active
- May convert pro-drug to active drug
- May bioactivate to toxic compound

A

Phase I

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5
Q

Hepatic Drug Metabolism:
- Primary conjugation
- Occurs in ER or cytosol
- Renders H2O soluble/less toxic/readily excreted
- Species differences
- Glutathione conjugation**
- Less susceptible (than Phase I) to the effects of disease and other drugs

A

Phase II
- Making things less toxic

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6
Q

(T/F) Hepatic dysfunction and effects of clearance can be predicted

A

False, unpredictable & complex

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7
Q

Characterize features:
- decreased albumin, decreased BUN, decreased cholesterol, decreased glucose
- increased SBA; coagulopathy not responsive to Vit K

A

Hepatocellular dysfunction (Metabolic dysfunction)

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8
Q

Characterize features:
- increased ALT/AST&raquo_space;> ALP

A

Hepatocellular injury

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9
Q

Characterize features:
- Increased ALP&raquo_space;> ALT
- Hyperbilirubinemia, bilirubinuria
- Increased cholesterol, Increased SBA, Vit K response coagulopathy

A

Cholestatic Disorder

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10
Q

Characterize features:
- Increased NH3; N to Increased FSBA/Increase PPSBA

A

Possible portosystemic shunting

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11
Q

** FILLER CARD **

A

Hepatobiliary Vascular Disorders and Hepatic Encephalopathy (Rudinsky - Feb 7th - In Class)
- These are the following cards after this

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12
Q
  • Anorexia - Dull
  • Lethargy - Difficulty training
  • Disorientation - Behavioral changes
  • Head-pressing* - Blindness
  • Circling, pacing - Hypersalivation
  • Ataxia - Seizures
  • Weakness - Coma
A

Hepatic Encephalopathy
- metabolic encephalopathy = signs can wax and wane; may be normal at times

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13
Q

(T/F) Brain effects of substances normally metabolized by the liver

A

True

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14
Q

Hepatic Encephalopathy: Neurologic disorder
Portosystemic Shunts:
- Single shunting vessel
- Intrahepatic (large breed dogs)
- Extrahepatic (cats, small dogs)

A

Congenital
- young animal showing early signs

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15
Q

Portosystemic Shunts:
- Multiple (2 degree to portal hypertension)
- Much less common

A

Acquired shunts

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16
Q

List the Clinical findings for PSS:

A
  • CNS signs
    • Hepatic encephalopathy
    • Hypersalivation (CATS)
  • GI signs
    • Intermittent vomiting/diarrhea
    • Pica/repeated FB ingestion
  • Urinary tract signs
    • pU/pD
    • Hematuria, dysuriaa, pollakiuria (urate stones)
  • Other
    • stunted growth, drug intolerance; prolonged anesthetic recovery
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17
Q

Hepatic Blood Flow (HBF)
- 20% of HBF

A

Arterial blood flow

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18
Q

Hepatic Blood Flow (HBF)
- 80% of HBF

A

Portal blood flow

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19
Q
  • Vascular communication between the portal and systemic venous systems
  • Portal blood bypasses the liver
A

Portosystemic Shunt

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20
Q

The portal blood drains from:

A
  • Intestines
  • Stomach
  • Pancreas
  • Spleen
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21
Q

If you see elevated bilirubin, is it useful to then go on and do Serum Bile acids testing?

A

No, because it’s the same saturable system
- Bilirubin is pulled out by hepatocytes from the blood & sent to excreted in the bile
- If bilirubin is increased, you will automatically have abnormal bile acids

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22
Q

** FILLER CARD **

A

Hepatobiliary Vascular Disorders and Hepatic Encephalopathy (Rudinsky - Feb 7th - In Class)

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23
Q
  • Radiography **
  • Ultrasonography (very dependent on the user, sensitivity is bad for this (inconclusive))
  • Angiography
    - Portogram
    - Arteriogram
    - Venogram
  • Portal scintigraphy (referral center)
  • CT/MRI (referral center)
    These are …
A

Imaging for Hepatobiliary disease

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24
Q

What are the treatments for Congenital PSS?

A
  • Medical management of HE
    - Protein-restricted diet
    - Lactulose, antibiotics
    - Correct precipitating events
  • Shunt attenuation (Surgery)
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25
Q

Congenital PSS
Definition:
- Is an inner ring of casein that is surrounded by a stainless steel sheath
- Slow closure –> gradual closure

A

Ameroid Constrictor
Complications:
- Portal Hypertension
- Seizure
- Hemorrhage
- Hypoglycemia
- Treatment Failure

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26
Q

** FOLLOWING CARDS **

A

***** Hepatobiliary Disease
Cholestatic Liver Dz, LECTURE 3 **

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27
Q

Cat with Yellow ear
What’s with the yellow?

A

Icterus or Jaundice
- Indicates that T bili > 2.5 mg/dl
- Bilirubinuria
- Rarely Acholic feces (complete bile duct obstruction)

28
Q
  • RBCs are broken down into three components and are repackaged and reutilized
  • HEME has to be ______________
A

Metabolized

29
Q

Definition:
- excess unconjugated bilirubin is produced faster than the liver is able to conjugate it for excretion
- anything that lyses RBCs
- Elevated unconjugated bilirubin in serum

A

Prehepatic (hemolytic) Jaundice
- IMHA
- Cats less common…

30
Q

What can you do to determine where the bilirubin is coming from?

A
  • PCV/TS **
  • CBC
  • Clin Path
31
Q

Cats
- Anemia signs predominate
- Anemia is usually regenerative (4-6 day lag time)
- Infectious Ddx
- Noninfectious Ddx
This describes …

A

Pre-hepatic Cats

32
Q

Definition:
- Hepatocytes can’t do their job, because something is blocking it
- Problem with liver
- Both conjugated and unconjugated bilirubin may be elevated in serum

A

Intrahepatic Jaundice (Hepatic)

33
Q

Definition:
- Impaired excretion due to mechanical obstruction to bile flow
- Elevated conjugated bilirubin in serum

A

Extrahepatic Jaundice (Post-hepatic)

34
Q

Variable appearance:
- Diffuse enlarged, hyperechogenicity

A

Hepatic lipidosis

35
Q

Variable appearance:
- Hypi/Iso/Hyperecho

A

Cholangiohepatitis

36
Q

Variable appearance:
- Nodules, diffuse hyper/ hypoechogenicity, mixed patterns

A

Neoplasia

37
Q

List the top three most common Cholestatic Liver Diseases:

A
  • Hepatic Lipidosis (30%)
    - Idiopathic
    - Secondary
  • Cholangitits (29%)
  • Neoplasia (23%)
38
Q

List the Diagnostics for Cholestatic Liver Disease:

A
  • Blood work
  • Imaging
  • Aspirates
  • Biopsy
  • Empirical treatment
39
Q
  • Most common feline liver disease
  • Obese cats, anorexia, wt loss
  • Massive hepatic fat accumulation
  • Intrahepatic cholestasis ***
  • Hepatic failure
  • Fatal without treatment, curable with food
A

Feline Hepatic Lipidosis

40
Q
  • Stressful Triggers (“Primary”)
    • Diet change
    • Boarding
    • Social environment (new pets, people, or home)
  • Nonhepatic catabolic illnesses (“Secondary”)

These are Clinical Associations for …

A

Feline Hepatic Lipidosis

41
Q
  • Middle-ag or older cats
  • No breed or sex predisposition
  • Prior obesity
  • Prolonged anorexia (> 2 weeks)
  • Weight loss (often >25%)
  • Vomiting, lethargy, diarrhea or constipation, hepatic encephalopathy infrequent
  • PE: icterus, hepatomegaly, dehydration, muscle wasting; ventroflexion of head/neck

These are Clinical Findings for …

A

Feline Hepatic Lipidosis

42
Q
  • Cholestatic pattern
    • Increase ALP > Increase ALT
      • But normal GGT
    • Hyperbilirubinemia
    • Bilirubinuria
    • Increase serum bile acids
    • Vit K responsive coagulopathy

These are Lab Findings for …

A

Feline Hepatic Lipidosis

43
Q

What is the “key” for hepatic lipidosis?

A

You feed them!
- once you put nutrients back into the system, it reverses it

44
Q
  • There are 3 types (rare disease)
    - Neutrophilic
  • Most common primary disease
  • Liver lobe involvement variable
  • Confusing literature
  • Different classification schemes
A

Feline Cholangitis

45
Q
  • Ascending biliary bacterial infection
    - Gram neg
    - anaerobes
  • Inflammation focused on bile ducts
  • Necrosis of hepatocytes beyond limiting plates

This is describing …

A

Feline Cholangitis - Neutrophilic

46
Q
  • Pancreatitis
  • IBD
  • Cholecystitis
  • Cholelithiasis
  • Sludged bile
  • Biliary obstruction

These are Associated Conditions for …

A

Neutrophilic Cholangitis

47
Q
  • Liver biopsy
  • Bacterial culture** better
    • Aerobic
    • Anaerobic
    • Liver or BILE
  • Surgery
    • If biliary obstruction

These are Diagnoses for …

A

Neutrophilic Cholangitis

48
Q
  • Chronic signs (tends to be less severe)
  • Middle-aged/older
  • Signs
    • Vomiting, diarrhea, jaundice
    • May be episodic
    • Hepatomegaly

This is describing …

A

Cholangitis - Lymphocytic

49
Q

List the indications for Liver Biopsy:
Methods
- ULS-guided (small samples)
- Laparoscopy
- Surgery

A
  • Persistent increase in liver enzymes or SBA
  • Abnormal hepatic parenchyma including liver mass(es)
  • Acute versus chronic
    - It is going to be better for Chronic disease evaluation
  • Obtain quantitative Cu
  • Monitor therapy
50
Q

Liver Biopsy
What are the Pre-biopsy Considerations (liver patients can bleed)?

A
  • Hemostasis evaluation
  • Method of biopsy
  • Pre-biopsy treatment
    • Vitamin K1
    • Plasma transfusion
51
Q

Liver Biopsy
What are your post-biopsy evaluations?

A

Monitor
- PCV
- TPP
- ULS
- Other

52
Q

When doing a liver biopsy, what evaluations are you doing?

A
  • Cytology
  • Histopathology
  • Culture
  • Chemical analysis
    - test for heavy metals
53
Q

What is a nutrient class that is most effective at reducing lipid accumulation in neg energy balance?

A

Protein

54
Q

What do fats and fat-soluble vitamins require for absorption?

A

Micelle formation

55
Q

Vitamin K Deficiency: Liver Disease
Treatment:
What route of administration is essential to treat vitamin K deficiency due to biliary obstruction?

A

Parenteral (IV, IM, SC not PO)

56
Q

Hepatoprotectants:
- Synthesized and found in almost every cell type
- Hepatocytes maintain particularly high levels
- Physiologic and metabolic functions
- Antioxidant

A

Glutathione

57
Q

Hepatoprotectants:
- Provide glutathione (antioxidant)
- Enteric-coated
- Empty stomach
- Nontoxic
- May cause upset stomachs

A

S-Adenosylmethionine (SAMe)

58
Q

Hepatoprotectants:
- Acts as a nutritional antioxidant

A

Vitamin E (alpha-Tocopherol)

59
Q

Hepatoprotectants:
- Flavonoid mixture
- Derived from seeds of Silybum marianum
- Natural liver remedy for >2000 years (ancient Greece)
- Variable amounts in products
- Variable absorption
- Herbal supplement (Antioxidant)
- Antifibrotic
- Anti-inflammatory
- Decrease hepatic uptake of Amanita mushroom toxicity

A

Milk Thistle (Silybin)

60
Q

Hepatoprotectants:
- Ursodeoxycholic acid
- 1-degree bile acid in Chinese Black Bear
- Hydrophilic bile acid
- Healing powers
- Now commercially synthesized
- Marketed for dissolution of cholesterol gallstones (man)
- Other effects on liver

A

Ursodiol (Actigall)
- Fav used in tOSU

61
Q

Hepatoprotectants:
What do we get from Ursodiol (Actigall)?

A
  • Anti-inflammatory
  • Anti-fibrotic
  • Immunomodulatory
  • Choleresis
    Mechanisms:
  • Replace hepatotoxic hydrophobic bile acids
62
Q

“Dog” Extrahepatic Cholestasis EHBDO:
- Is an inappropriate accumulation of mucus or inspissated bile in the gallbladder lumen

A

Gallbladder Mucocele
- Kiwi appearance

63
Q

“Dog” Extrahepatic Cholestasis EHBDO:
- Is a medical condition resulting from the formation of stones in the gallbladder

A

Cholelithiasis

64
Q

“Dog” Extrahepatic Cholestasis EHBDO:
- Tumors, etc

A

Biliary Obstruction

65
Q

List what to do to manage Biliary Obstruction:

A
  • Vitamin K
    • Parenteral
    • 24-48 hrs
  • Antibiotics
  • Exploratory surgery
    • Relive obstruction
    • Bacterial culture
    • Tissue biopsy

Digestive System Exam 2 (11 decks)

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