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Medically Complex Tx Planning > 4. Liver Disease > Flashcards

4. Liver Disease Flashcards

1
Q

What are the functions of the liver?

A
  • Fat absorption
  • Metabolism of:
    • Sugar, amino acids, ammonia, protein, carbohydrates, lipids
  • Excretion of bilirubin
  • Synthesis of coagulation factors
  • Drug metabolism
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2
Q

What are the different types of liver disease?

A
  • Viral Hepatitis (A,B,C,D,E)
  • Alcoholic Liver Disease (alcoholic hepatitis)
  • Cirrhosis
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3
Q

Which viruses are the most devastating for liver disease?

A
  • B, C, D
  • Acute/Chronic
  • Cause hepatocellular carcinoma
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4
Q

Which two hepatitis viruses have severe complications leading to cirrhosis and hepatocellular carcinoma?

A

B & C

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5
Q

What is the pathogenesis of viral hepatitis?

A
  • Majority resolve without complication
  • However some lead to consequences:
    • Persistent infection
    • Chronic active infection
    • Dual infection
    • Fulminant hepatitis
    • Cirrhosis
    • Hepatocellular carcinoma
    • Death
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6
Q

What is the pathogenesis of alcoholic liver disease?

A
  • Fatty liver -> alcoholic hepatitis -> cirrhosis
    • Fatty liver - enlarged, steatosis (reversible)
    • Alcoholic hepatitis - increased AST, jaundice, abdominal pain
    • Cirrhosis - scarred, fibrous, shrinks, loss of normal function, irreversible
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7
Q

What are some of the important questions to ask when considering a patient has viral hepatitis?

A
  • Does pt have any signs of liver disease?
  • Drink alcohol? How much?
  • Bruise easily?
  • Diagnosed with cirrhosis?
  • When was most recent blood test?
  • INR? (should be <3.5)
  • History of substance or drug abuse?
  • Vaccination history (Hep A/B?)
  • Any extrahepatic manifestations of liver disease?
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8
Q

What are the important questions to ask when considering alcholic liver disease?

A
  • Drink alcohol?
  • How much?
  • How often?
  • How long?
  • Been diagnosed with cirrhosis or liver disease?
  • Bruise easily?
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9
Q

What can patients present with orally if they have liver disease?

A
  • Increased bleeding
  • Lichenoid lesions
  • Sjogren’s like syndrome
  • Metastasis of hepatocellular carcinoma (mandible)
  • Jaundice of the mucosa
  • Sialosis
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10
Q

Patients with cirrhosis/end stage liver disease may have increased bleeding risks, what should their platelet count and their INR be?

A
  • Platelet count - >50,000
  • INR <3.5 for most surgical procedures
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11
Q

What factors are invovled with vitamin K factors for blood clotting?

A

2,7,9,10

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12
Q

When bleeding needs to be managed with cooperation with the physician, what might it include?

A
  • Hemostatic agents
  • Fresh frozen plasma
  • Vitamin K
  • Platelets
  • Antifibrinolytic agents
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13
Q

A patient undergoing active treatment for viral hepatitis may have neutropenia. When should antibiotic prophylaxis be required in this situation?

A

If the neutrophil count falls below <0.5

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14
Q

What are the factors that play a role in the increased susceptibility to infection in alcoholic liver disease?

A
  • Invasive procedures, due to diminished immune function, which allows for bacteremia
  • Antibiotics should be prescribed when oral infection is present and when it is unlikely that the infection will resolve without treatment.
  • Physician consultation is warranted
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15
Q

What alterations should be made regarding the analgesics, in liver disease patients?

A
  • Avoid NSAIDS and Aspirin!!!
  • Acetaminophen is relatively safe (limited to <4g/day)
  • Codeine, Hydrocodone and oxycodone should be used at increased dose intervals, since they are conjugated by the liver. Only for short term.
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16
Q

Are local anesthetics safe to use?

A

Yes

  • Doses should be below 7mg/kg when combined with epinephrine
    • Up to 13 cartridges of 2% lidocaine with epi 1:100,000 is safe
  • Consider articaine or prilocaine, as these are metabolized in the plasma and partially in the lungs, respectively.
17
Q

What anesthetic is metabolized in the plasma and which one is in the lungs?

A
  • Plasma - Articaine
  • Lungs - Prilocaine
18
Q

Are benzodiazepines safe for liver disease patients?

A

Yes - but require decreased dosages!

19
Q

What kind of antibiotics could be used in liver disease patients?

A
  • Beta-lactam antibiotics can be used safely
    • Penicillin, amoxicillin, cephalexin, cefazolin, ceftraizone
  • Metronidazole
    • Use with caution and increased dose intervals in patients with severe liver diseaes (acute hepatitis or cirrhosis)
  • Tetracycline, minocycline and doxycycline should be used at reduced dosages and increased dose intervals.
20
Q

What antibiotics should be avoided in patients with severe liver disease?

A
  • Clindamycin
  • Aminoglycosides
  • Vancomycin
  • Macrolides
21
Q

Why would you want to avoid the use of CNS depressants (barbituates, benzo’s, opiates, sedatives)?

A

With alcohol - run the risk of overdosing patient

22
Q

Why would you possibly need an increased dose of local anesthetics, sedative and hypnotic drugs and general anesthesia in patient with liver disease?

A

Enzyme induction

23
Q

Patients with untreated alcoholic liver disease are candidates for elective, outpatient dental care (T/F)?

A

False - they are not

24
Q

Can patients with viral hepatitis be seen in the dental clinic?

A

Yes - no concerns outside the existing guidelines

25
Q

Can you treat a patient with active hepatitis?

A

No - do not treat elective Tx

26
Q

When would you send a med consult for viral hepatitis patients?

A

When Hepatitis B and C are not active, but need more info.

27
Q

Can you treat a resolved hepatitis A patient?

A

Yes - resolved = ok to treat

28
Q

What care should be taken when treating an patient with an acute disease for emergency treatment?

A
  • Standard precautions
  • Minimize aerosolization & avoid drugs metabolized by liver
  • Evaluate labs (PT, bleeding time, platelet levels, INR) prior to invasive therapy
  • Refer pt back to physcian
  • NO elective treatment
29
Q

What do you need to ensure in a med consult?

A
  • Status of hepatitis (active or carrier)?
  • Acute symptoms?
  • Platelets > 50,000
  • INR < 3.5
    *
30
Q

What should you do when ALT and AST are 4x normal and/or diagnosis of Cirrhosis?

A
  • Drug dosages should be modified (consider half the normal adult dose)
31
Q

What is the cage model for screening for alcohol abuse?

A
  • C -Have you ever felt you needed to Cut down on your drinking?
  • A - Have people Annoyed you by criticizing your drinking?
  • G - Have you ever felt Guilty about drinking
  • E - Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Medically Complex Tx Planning (7 decks)

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