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Small Animal Medicine II > Acute Hepatobiliary Disease > Flashcards

Acute Hepatobiliary Disease Flashcards

1
Q

How does acute liver disease compare to chronic?

A

sudden onset of more severe clinical signs

  • disease may not be acute onset, but signs and presentation can be acute –> chronic disease leads to liver failure
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2
Q

What are 2 characteristics of acute liver injury? How does this compare to acute liver failure?

A
  1. hepatocellular damage and necrosis
  2. retained hepatic function

FAILURE = decreased hepatic function due to sudden loss of >70% hepatic functional mass

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3
Q

What are the 6 most common cause of hepatobiliary disease?

A
  1. infectious - acute
  2. inflammatory - chronic
  3. neoplastic - lymphoma = acute, adenocarcinoma = chronic
  4. metabolic - lipidosis = acute
  5. toxic - acute
  6. GBM/stones - acute due to rupture, chronic development
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4
Q

How can systemic disease cause liver disease? What are 5 common etiologies?

A

disease remove from the liver causes elevated liver enzymes, usullay <2-3x RI (higher indicative of liver disease or pancreatitis)

  1. sepsis
  2. systemic infection - Rickettsial, Leptospirosis
  3. inflammation - GI disease, pancreatitis
  4. hypoxia - anemia
  5. endocrine
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5
Q

What are some signs of acute liver disease?

A
  • anorexia with poor appetite
  • vomiting +/- diarrhea
  • abdominal pain
  • melena/hematemesis
  • bleeding tendencies - petechia, melena, hematemesis
  • icterus
  • encephalopathy - increased ammonia unable to be metabolized into urea
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6
Q

What history is especially important to collect in patients with potential acute liver disease?

A
  • presence and severity
  • duration
  • exposure to drugs or toxins
  • travel history (fungal infection)
  • exposure to infectious disease
  • vaccination status
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7
Q

What may be observed on physical exam in cases of acute liver disease?

A
  • icterus
  • hepatoencephalopathy
  • liver size
  • distended abdomen - ascites due to decreased albumin and portal hypertension
  • evidence of bleeding disorder - petechia, melena
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8
Q

What 3 changes in biochemistry are observed in cases of acute liver disease?

A
  1. hepatic enzymes - severity of disease, not indicative of reversibility of disease/recovery
  2. high bilirubin - hepatocytes cannot metabolize
  3. markers of liver function - albumin, cholesterol, glucose, BUN
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9
Q

What are the 3 possible patterns of hepatic enzyme increase?

A
  1. CHOLESTATIC = ALP > ALT +/- hyperbilirubinemia, more commonly chronic
  2. HEPATOCELLULAR = ALT > ALP +/- hyperbilirubinemia, more commonly acute
  3. MIXED = ALT = ALP +/- hyperbilirubinemia
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10
Q

What are bile acid measurements helpful? What can affect their levels?

A

indicate hepatic function –> NO indication of reversibility or severity of disease

cholestasis - not performed in icteric patients

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11
Q

How are bile acid results interpreted? What is the gray zone?

A
  • > 25-30 = liver disease likely
  • > 30 pre or post

25-40

(highly specific)

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12
Q

What are the most common results of Leptospirosis?

A

acute kidney injury with or without hepatic injury

  • hepatic injury alone not likely
  • G-, obligate aerobe, spirochete
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13
Q

What are the most common clinical signs of Leptospirosis?

A
  • vomiting, diarrhea
  • PU/PD
  • icterus
  • anorexia
  • arthralgia, myalgia
  • fever
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14
Q

What clinicopathology changes are seen with Leptospirosis?

A
  • LIVER and KIDNEY INJURY = elevated liver enzymes + azotemia
  • HEMOSTASIS = petechia due to widespread vasculitis
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15
Q

How is Leptospirosis diagnosed?

A
  • PCR of blood and urine
  • WITNESS rapid Ab test - measures IgM, which can be increased with vaccination status
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16
Q

In what patients is adenovirus-1 infection most common?

A

young, unvaccinated dogs

17
Q

What are 5 common toxins that cause acute liver disease?

A
  1. xylitol - >0.5 g/kg = hepatic failure; 0.1 g/kg = hypoglycemia
  2. amanita mushroom
  3. sago (Cycad) palms
  4. blue-green algae (lakes!)
  5. aflatoxins
18
Q

What are 3 steps to treating toxic liver disease?

A
  1. remove inciting cause
  2. decontaminate as needed if there is known ingestion before liver injury
  3. supportive care - IV fluids, symptomatic treatment, hepatoprotectants (Denamarin, SAMe)
19
Q

What are 10 drugs that typically cause liver disease?

A
  1. Phenobarbital
  2. Diazepam (cats)
  3. Azathioprine
  4. TMS
  5. tetracyclines
  6. Acetaminophen
  7. Carprofen
  8. azoles - Itraconazole, Ketoconazole
  9. Methimazole (cats)
  10. Lomustine (CCNU)
20
Q

What are 2 common results of drug/toxin hepatic disease?

A
  1. acute injury
  2. cirrhosis
21
Q

What are the 4 most common chronic drug/toxic causes of acute liver disease?

A
  1. Phenobarbital
  2. Primidone
  3. Phenytoin
  4. Lomustine
22
Q

What are some drugs that cause dose-dependent and idiosyncratic liver disease?

A

DOSE-DEPENDENT - Phenobarbital, Azoles –> if treatment needed, can lower dosage

IDIOSYNCRATIC - Carprofen, Sulfas –> must discontinue

23
Q

What is the most common cause of acute liver disease?

A

idiopathic

  • general and hepatic supportive care
24
Q

What is prognosis of acute liver injury like?

A

VARIABLE, depends on inciting cause and response to treatment

  • guarded with acute liver failure
25
Q

What are 4 parts of supportive care necessary in cases of acute liver disease?

A
  1. IV fluid therapy
  2. liver support - antioxidants
  3. nutrition
  4. identification and management of complications

need time for liver to recover

26
Q

What are the 4 most common antioxidants used for supportive therapy in cases of acute liver disease? What toxicity do they work especially well for?

A
  1. SAMe - glutathione detoxification
  2. N-acetylcysteine - stimulates glutathione synthesis, detoxifies, and is a free radical scavenger
  3. Silymarin (milk thistle) - induces antioxidant system, scavengers ROS
  4. vitamin C - scavengers ROS

Acetaminophen - builds up NAPQI, which is detoxified by glutathione (Silymarin good for amanita mushrooms, too!)

27
Q

What 3 functions does Ursodiol have in cases of acute liver disease? When is it used? When is it contraindicated?

A
  1. chloerectic
  2. anti-inflammatory
  3. immunomodulatory

cholangitis, GBM, cholecystitis +/- hepatitis

complete biliary obstruction

28
Q

What are 4 indications for antibiotic usage in cases of acute liver disease? Which are used in each cause?

A
  1. bacterial cholangitis or cholecystitis = Clavamox +/- fluoroquinolones
  2. Leptospirosis - Doxycycline, Amoxicillin
  3. Rickettsial disease - Doxycyclines
  4. sepsis

(C&S always recommended)

29
Q

How are coagulopathies associated with acute liver disease treated?

A
  • FPF - active hemorrhage or procedures that induce hemorrhage
  • Vitamin K - cholestatic disorders with coagulopathies
30
Q

What fluid therapy is recommended in cases of acute liver disease? What may be avoided?

A
  • resuscitation- hypovolemic shock, hypotension
  • balances crystalloids
  • add dextrose and electrolytes

LRS –> lactate buffer requires functional hepatocytes fo metabolism

(maintenance, hydration, losses)

31
Q

Other than hepatoprotectants and antioxidants, what 2 classes of drugs are recommended for acute liver disease?

A
  1. antiemetics - vomiting –> Cerenia, Ondansetron, Dolansetron
  2. gastric acid reducing drugs - GI hemorrhage/ulceration –> PPIs (Pantoprazole)
32
Q

What nutrition is recommended for cases of acute liver disease? When is this not recommended?

A

high-quality protein, highly digestible (GI diets)

hepatoencephalopathy - initial protein restriction with titration to effect

(may need NE or NG tube for delivery)

Small Animal Medicine II (57 decks)

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