4. Liver Disease Flashcards
What are the functions of the liver?
- Fat absorption
- Metabolism of:
- Sugar, amino acids, ammonia, protein, carbohydrates, lipids
- Excretion of bilirubin
- Synthesis of coagulation factors
- Drug metabolism
What are the different types of liver disease?
- Viral Hepatitis (A,B,C,D,E)
- Alcoholic Liver Disease (alcoholic hepatitis)
- Cirrhosis
Which viruses are the most devastating for liver disease?
- B, C, D
- Acute/Chronic
- Cause hepatocellular carcinoma
Which two hepatitis viruses have severe complications leading to cirrhosis and hepatocellular carcinoma?
B & C
What is the pathogenesis of viral hepatitis?
- Majority resolve without complication
- However some lead to consequences:
- Persistent infection
- Chronic active infection
- Dual infection
- Fulminant hepatitis
- Cirrhosis
- Hepatocellular carcinoma
- Death
What is the pathogenesis of alcoholic liver disease?
- 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
What are some of the important questions to ask when considering a patient has viral hepatitis?
- 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?
What are the important questions to ask when considering alcholic liver disease?
- Drink alcohol?
- How much?
- How often?
- How long?
- Been diagnosed with cirrhosis or liver disease?
- Bruise easily?
What can patients present with orally if they have liver disease?
- Increased bleeding
- Lichenoid lesions
- Sjogren’s like syndrome
- Metastasis of hepatocellular carcinoma (mandible)
- Jaundice of the mucosa
- Sialosis
Patients with cirrhosis/end stage liver disease may have increased bleeding risks, what should their platelet count and their INR be?
- Platelet count - >50,000
- INR <3.5 for most surgical procedures
What factors are invovled with vitamin K factors for blood clotting?
2,7,9,10
When bleeding needs to be managed with cooperation with the physician, what might it include?
- Hemostatic agents
- Fresh frozen plasma
- Vitamin K
- Platelets
- Antifibrinolytic agents
A patient undergoing active treatment for viral hepatitis may have neutropenia. When should antibiotic prophylaxis be required in this situation?
If the neutrophil count falls below <0.5
What are the factors that play a role in the increased susceptibility to infection in alcoholic liver disease?
- 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
What alterations should be made regarding the analgesics, in liver disease patients?
- 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.
Are local anesthetics safe to use?
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.
What anesthetic is metabolized in the plasma and which one is in the lungs?
- Plasma - Articaine
- Lungs - Prilocaine
Are benzodiazepines safe for liver disease patients?
Yes - but require decreased dosages!
What kind of antibiotics could be used in liver disease patients?
- 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.
What antibiotics should be avoided in patients with severe liver disease?
- Clindamycin
- Aminoglycosides
- Vancomycin
- Macrolides
Why would you want to avoid the use of CNS depressants (barbituates, benzo’s, opiates, sedatives)?
With alcohol - run the risk of overdosing patient
Why would you possibly need an increased dose of local anesthetics, sedative and hypnotic drugs and general anesthesia in patient with liver disease?
Enzyme induction
Patients with untreated alcoholic liver disease are candidates for elective, outpatient dental care (T/F)?
False - they are not
Can patients with viral hepatitis be seen in the dental clinic?
Yes - no concerns outside the existing guidelines
