Acute Hepatobiliary Disease Flashcards
How does acute liver disease compare to chronic?
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
What are 2 characteristics of acute liver injury? How does this compare to acute liver failure?
- hepatocellular damage and necrosis
- retained hepatic function
FAILURE = decreased hepatic function due to sudden loss of >70% hepatic functional mass
What are the 6 most common cause of hepatobiliary disease?
- infectious - acute
- inflammatory - chronic
- neoplastic - lymphoma = acute, adenocarcinoma = chronic
- metabolic - lipidosis = acute
- toxic - acute
- GBM/stones - acute due to rupture, chronic development
How can systemic disease cause liver disease? What are 5 common etiologies?
disease remove from the liver causes elevated liver enzymes, usullay <2-3x RI (higher indicative of liver disease or pancreatitis)
- sepsis
- systemic infection - Rickettsial, Leptospirosis
- inflammation - GI disease, pancreatitis
- hypoxia - anemia
- endocrine
What are some signs of acute liver disease?
- 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
What history is especially important to collect in patients with potential acute liver disease?
- presence and severity
- duration
- exposure to drugs or toxins
- travel history (fungal infection)
- exposure to infectious disease
- vaccination status
What may be observed on physical exam in cases of acute liver disease?
- icterus
- hepatoencephalopathy
- liver size
- distended abdomen - ascites due to decreased albumin and portal hypertension
- evidence of bleeding disorder - petechia, melena
What 3 changes in biochemistry are observed in cases of acute liver disease?
- hepatic enzymes - severity of disease, not indicative of reversibility of disease/recovery
- high bilirubin - hepatocytes cannot metabolize
- markers of liver function - albumin, cholesterol, glucose, BUN
What are the 3 possible patterns of hepatic enzyme increase?
- CHOLESTATIC = ALP > ALT +/- hyperbilirubinemia, more commonly chronic
- HEPATOCELLULAR = ALT > ALP +/- hyperbilirubinemia, more commonly acute
- MIXED = ALT = ALP +/- hyperbilirubinemia
What are bile acid measurements helpful? What can affect their levels?
indicate hepatic function –> NO indication of reversibility or severity of disease
cholestasis - not performed in icteric patients
How are bile acid results interpreted? What is the gray zone?
- > 25-30 = liver disease likely
- > 30 pre or post
25-40
(highly specific)
What are the most common results of Leptospirosis?
acute kidney injury with or without hepatic injury
- hepatic injury alone not likely
- G-, obligate aerobe, spirochete
What are the most common clinical signs of Leptospirosis?
- vomiting, diarrhea
- PU/PD
- icterus
- anorexia
- arthralgia, myalgia
- fever
What clinicopathology changes are seen with Leptospirosis?
- LIVER and KIDNEY INJURY = elevated liver enzymes + azotemia
- HEMOSTASIS = petechia due to widespread vasculitis
How is Leptospirosis diagnosed?
- PCR of blood and urine
- WITNESS rapid Ab test - measures IgM, which can be increased with vaccination status
In what patients is adenovirus-1 infection most common?
young, unvaccinated dogs
What are 5 common toxins that cause acute liver disease?
- xylitol - >0.5 g/kg = hepatic failure; 0.1 g/kg = hypoglycemia
- amanita mushroom
- sago (Cycad) palms
- blue-green algae (lakes!)
- aflatoxins
What are 3 steps to treating toxic liver disease?
- remove inciting cause
- decontaminate as needed if there is known ingestion before liver injury
- supportive care - IV fluids, symptomatic treatment, hepatoprotectants (Denamarin, SAMe)
What are 10 drugs that typically cause liver disease?
- Phenobarbital
- Diazepam (cats)
- Azathioprine
- TMS
- tetracyclines
- Acetaminophen
- Carprofen
- azoles - Itraconazole, Ketoconazole
- Methimazole (cats)
- Lomustine (CCNU)
What are 2 common results of drug/toxin hepatic disease?
- acute injury
- cirrhosis
What are the 4 most common chronic drug/toxic causes of acute liver disease?
- Phenobarbital
- Primidone
- Phenytoin
- Lomustine
What are some drugs that cause dose-dependent and idiosyncratic liver disease?
DOSE-DEPENDENT - Phenobarbital, Azoles –> if treatment needed, can lower dosage
IDIOSYNCRATIC - Carprofen, Sulfas –> must discontinue
What is the most common cause of acute liver disease?
idiopathic
- general and hepatic supportive care
What is prognosis of acute liver injury like?
VARIABLE, depends on inciting cause and response to treatment
- guarded with acute liver failure
What are 4 parts of supportive care necessary in cases of acute liver disease?
- IV fluid therapy
- liver support - antioxidants
- nutrition
- identification and management of complications
need time for liver to recover
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?
- SAMe - glutathione detoxification
- N-acetylcysteine - stimulates glutathione synthesis, detoxifies, and is a free radical scavenger
- Silymarin (milk thistle) - induces antioxidant system, scavengers ROS
- vitamin C - scavengers ROS
Acetaminophen - builds up NAPQI, which is detoxified by glutathione (Silymarin good for amanita mushrooms, too!)
What 3 functions does Ursodiol have in cases of acute liver disease? When is it used? When is it contraindicated?
- chloerectic
- anti-inflammatory
- immunomodulatory
cholangitis, GBM, cholecystitis +/- hepatitis
complete biliary obstruction
What are 4 indications for antibiotic usage in cases of acute liver disease? Which are used in each cause?
- bacterial cholangitis or cholecystitis = Clavamox +/- fluoroquinolones
- Leptospirosis - Doxycycline, Amoxicillin
- Rickettsial disease - Doxycyclines
- sepsis
(C&S always recommended)
How are coagulopathies associated with acute liver disease treated?
- FPF - active hemorrhage or procedures that induce hemorrhage
- Vitamin K - cholestatic disorders with coagulopathies
What fluid therapy is recommended in cases of acute liver disease? What may be avoided?
- resuscitation- hypovolemic shock, hypotension
- balances crystalloids
- add dextrose and electrolytes
LRS –> lactate buffer requires functional hepatocytes fo metabolism
(maintenance, hydration, losses)
Other than hepatoprotectants and antioxidants, what 2 classes of drugs are recommended for acute liver disease?
- antiemetics - vomiting –> Cerenia, Ondansetron, Dolansetron
- gastric acid reducing drugs - GI hemorrhage/ulceration –> PPIs (Pantoprazole)
What nutrition is recommended for cases of acute liver disease? When is this not recommended?
high-quality protein, highly digestible (GI diets)
hepatoencephalopathy - initial protein restriction with titration to effect
(may need NE or NG tube for delivery)
