Exam 3: Hepatic & Biliary Flashcards
What is gluconeogenesis?
The process by which the liver synthesizes glucose.
How does the liver store excess glucose?
As glycogen.
What substances does the liver synthesize?
Cholesterol, proteins, hormones, and vitamins.
What does the liver metabolize to generate energy?
Fats, proteins, and carbohydrates.
Which enzyme pathways are involved in drug metabolism in the liver?
CYP-450 and other enzyme pathways.
What is one major role of the liver in detoxification?
Detoxifies blood.
How does the liver contribute to immune support?
Involved in the acute phase of immune support.
The liver processes _____ and stores _____.
hemoglobin
iron
What are the coagulation factors synthesized by the liver?
All except factors III, IV, VIII, and vWF.
How many segments is the liver divided into?
8 segments
What separates the right and left lobes of the liver?
Which is larger?
Falciform ligament
R lobe > left lobe
What is the primary function of the portal vein and hepatic artery?
perfuse each segment of liver
What percentage of cardiac output does the liver receive?
25%
via portal vein and hepatic artery
1.25-1.5 L/min
highest proportionate CO of all organs
What is the hepatic artery and portal vein contribution to hepatic blood flow?
O2 delivery?
Hepatic artery: 25% HBF
Portal vein: 75% HBF
*partially deoxygenated
O2 delivery: 50/50
What does increased portal venous pressure lead to?
Blood backs up into the systemic circulation, potentially causing esophageal and gastric varices.
How is hepatic blood flow autoregulated?
The hepatic artery dilates in response to low portal venous flow.
What are the vague symptoms of late-stage liver disease?
Disrupted sleep and decreased appetite
*often asymptomatic
What are common risk factors for cholelithiasis?
Percentage asympatomatic?
- Obesity
- Increased cholesterol
- Diabetes mellitus
- Pregnancy
- Female gender
- Family history
80%
Choledocholithiasis:
Cause:
S/S:
TX:
S/S: N/V, cramping, RUQ pain
Cholangitis s/s: fever, rigors, jaundice
Endoscopic removal of the stone via ERCP
- guidewire through Sphincter of Oddi into Ampulaa of Vator to retrieve the stone from the pancreatic duct or CBD
- Glucagon 1 mg treats Oddi spasm
- GA, prone w/ ET tube left side
What is the most common cause of viral hepatitis requiring liver transplant in the US?
Hepatitis C virus
Non-Alcoholic Fatty Liver Disease (NAFLD)
diagnosis:
TX:
Liver biopsy: gold standard
Imaging, histology
Hepatocytes contain >5% fat
TX: diet, exercise, transplant
Two scoring systems to determine the severity of liver disease?
CTP (child Turcotte Pugh): bili, albumin, PT, encephalopathy, ascites
MELD (model for end-stage liver disease): bilirubin, INR, creatinine, and sodium
Hepatorenal Syndrome
what is it?
TX?
excess production of endogenous vasodilators (NO, PG) -> decreased RBF
Midodrine, Octreotide, Albumin
What does the term ‘TIPS’ stand for in liver management?
Transjugular Intrahepatic Portosystemic Shunt
What are the contraindications for TIPS procedure?
HF, tricuspid regurg, severe pulmonary HTN
What is the purpose of partial hepatectomy?
Resection to remove neoplasms and provide adequate tissue for regeneration
What percentage of liver can be removed in patients with normal liver function?
Up to 75%
What may the surgeon clamp to control blood loss during liver resection?
IVC or hepatic artery
What post-operative care do patients often require after liver resection?
Post op PCA
What is the most common indication for liver transplant?
Alcoholic liver disease
How does the liver aid in volume control?
blood reservior
What empties into the IVC?
right, middle, left hepatic veins
The hepatic artery branches off the ________.
aorta
What is hepatic arterial blood flow inversely realted to?
portal venous flow
Normal hepatic pressure
1-5 mmHg
Hepatic pressure for portal HTN?
variceal rupture?
> 10 mmHg
> 12 mmHg
Risk factors for liver impairment:
family history
ETOH, drug use
DM
obesity
mult. partners
tattoos (DYI, dirty needles)
transfusions (rare)
Physical exam liver impairment S/S
pruritis
jaundice
ascites
asterixis (flapping tremor)
hepatomegaly
splenomegaly
spider nevi
Most specific enzymes for hepato-biliary function
AST, ALT
What are the 3 groups of hepato-biliary disease?
hepatocellular injury
- acute liver injury
- alcoholic liver disease
- NAFLD
reduced synthetic function
cholestasis
hepatocellular injury:
types and labs
low albumin
high PT
high conjugated bili
high AST/ALT:
*acute liver disease: 25X elevated
*alcoholic liver disease: 2:1
*NAFLD: 1:1
Reduced synthetic function: labs
low albumin
high PT/INR
Cholestasis: labs
high phosphatase
high GGT
high conjugated bili
**low bile flow
Hemolysis bili overload: what lab is increased?
only unconguated bili
Cholelithiasis:
S/S
TX:
aka gallstones:
80% asymptomatic
RUQ pain
N/V, indigestion
fever (acute obstruction)
TX: IVF, abx, pain mangement,
LAP CHOLE (remove gallbladder)
What is the product of heme breakdown?
bilirubin
what does non-alcoholic fatty liver disease progress to?
NASH, cirrohsis, hepatocellular carcinoma
Unconjugated Bilirubin
causes of high levels?
aka indirect
protein bound to albumin, transported to liver, conjugated to H2O soluble “direct” state, excreted in bile
*high levels: imbalances between bili synthesis and conjugation
Conjugated Bilirubin
causes of high levels?
aka direct
*obstruction resulting in reflux into circulation
What types of hepatitis are more chronic?
B, C
How many types of hepatitis?
5
A-E
Why is hepatitis incidence decreasing?
vaccines
new treatments:
- 12 wks Sofosbuvir/Velpatasvir
- 98-99% clearance of genotype 1A/1B of hep C
- HCV genotype 75% type 1
mode of transmission for Hepatitis B and C?
Percentages?
transfusions
percutaneous
sexual
perinatal
Hep B: 1-5% adults, 80-90% kids
Hep C: 76% chronic liver disease
Platelet level of alcoholic liver disease, needing transfusion?
<50,000
Labs for alcoholic liver disease
high:
mean corpuscular volume
liver enzymes
GGT
Bili
ETOH level
How many people have NAFLD regardless of weight?
1 out of 4
More than ____ diabetics and ______ obese people have NAFLD
6
9/10
Autoimmune Hepatitis primarily affects ____. May be ____, ____, or _____. Positive _____ and hypergammaglobulinemia.
AST/ALT _____x normal value.
Percentage remission?
Treatment?
women
asymptomatic, acute, or chronic
+autoantibodies
10-20X
remission: 60-80%
relaspe common
TX: steroids, azathioprine (immunosuppressant), transplant if needed
Most common cause of drug induced liver injury?
acetaminophen
normally reversible when drug is removed
What are the 3 types of Inborn Errors of Metabolism?
Occur in what ratio of births?
What are they?
wilsons disease
alpha-1 antitrypsin deficiency
hemochromatosis
1:25000 births
genetic inherited disorders w/defects in enzymes breaking down & storing protein, carbs, fatty acids
Neonatal period -> high mortality
Wilsons Disease aka _____.
Leads to oxidative stress in the liver, basal ganglia, and cornea from _____ build-up.
S/S:
Diagnosis:
TX:
hepatolenticular degeneration
copper
S/S: asymptomatic, severe liver dysfunction, neurological and psychologic manifestations
Dx: serum ceruloplasmin, aminotransferase, urine copper level, liver biopsy
TX: copper chelation therapy, oral zinc (binds copper in GI)
What’s the #1 cause for liver transplant in children?
Alpha-1 antitrypsin deficiency
Alpha-1 anti-trypsin deficiency results from defective ______ protein, which normally protects liverand lungs from ______ ______.
diagnosis:
TX:
alpha-1 antitrypsin
neutrophil elastase
diagnosis: phenotyping
TX: pooled alpha-1 antitrypsin for pulmonary symptoms
** Transplant only cure
Hemochromatosis is excessive intestinal absorption of _____, which causes _____.
May be genetic, repetitive blood transfusions, or _____ infusions.
Present in?
labs:
DX:
TX:
Iron -> tissue damage
iron transfusions
present in cirrhosis, HF, DM, adrenal insufficiency, poly arthropathy
high AST/ALT, transferring, ferritin
Dx: genetic mutation, ECHO, MRI, liver biopsy
TX: weekly phlebotomy, iron chelating drugs, transplant
Hepatic Encephalopathy caused by buildup of _____ _____.
S/S:
TX:
nitrogenous waste
neuropsychotic, cognitive impairment
lactulose
Rifaximin: decreases ammonia production bacteria in the gut
Hepatopulmonary Syndrome triad includes:
liver disease
hypoxemia
intrapulmonary vascular dilation
**platypnea (hypoxia when upright) right to left shunt
Portopulmonary HTN
causes:
TX:
pulm. HTN and portal HTN
systemic vasodilation triggering pulmonary vasoconstrictor production
TX: PD-I, NO, prostacyclin analogs, endothelin receptors antagonists
*** Transplant only cure
What 2 NMB not metabolized by the liver
Sux and Cis
** but plasma cholinesterase may be decreased
Alcohol can ______ MAC of volatiles.
increase
Colloids or crystalloids?
colloids
*liver no longer producing albumin
TIPS: stent/graft placed in the _____ and _____ vein.
portal vein
hepatic vein
** shunts blood to systemic circulation
Purpose of TIPS?
portal HTN
refractory variceal hemorrhage, ascites
During partial hepatectomy, you want to maintain CVP _____, to reduce blood loss.
low
What can post-op liver resection cause?
coagulation disturbances
Primary Sclerosing Cholangitis:
Autoimmune, chronic inflammation of ___ ___ ___.
Intrahepatic and ______.
Biliary tree fibrosis looks like?
males vs females
S/S:
DX:
TX:
larger bile ducts
intrahepatic and extrahepatic
beads on a string
Males > females, onset 40s
S/S: fatigue, itching, deficient fat-soluble vitamins (A,D,E,K), cirrhosis
*high alkalinity phos, GGT
* positive antibodies
liver biopsy
no drug TX
Transplant only long-term tx (but reoccurrence can happen since autoimmune)
Primary Biliary Cholangitis previously called ___ _____. Autoimmune destruction of ____ _____.
males vs female?
Causes?
S/S:
labs:
imaging:
TX:
biliary cirrhosis
bile ducts
Male > female
Middle age
causes: environmental toxins
S/S: jaundice, fatigue, itching
labs: high alkalinity phos, GGT, + antimicrobial antibodies
MRI, CT, MRCP, biopsy
TX: no cure; exogenous bile acids
Causes of acute liver failure?
What percentage is drug induced?
viral hepatitis, autoimmune, hypoxia, ALF of pregnancy, HELLP
drug induced 50%
Occurrence of acute liver failure after insult?
days to 6 months after the insult
Acute liver failure leads to rapid increase in _____ and _____, altered mental status, and ______, and hepatocyte necrosis.
S/S:
AST/ALT
coagulpathy
S/S: jaundice, N/V, RUQ pain, cerebral edema, encephalopathy, MOF
Most common causes of cirrhosis?
ALD
NAFL
Hep C
Hep B
What’s the cure for cirrhosis?
transplant
What labs are elevated in cirrhosis?
AST/ALT
bili
Alk phos
PT/INR
thrombocytopenia
What is the final stage of liver disease, often asymtomaptic in early stages. Normal liver parenchya is replaced with scar tissue.
Cirrosis
What does cirrohsis lead to?
jaundice, ascites, varices, coagulopathy, encephalopathy, bacterial peritonitis (abx)
What is present in 50% of cirrosis patients?
varices
What’s the most lethal complication of cirrhosis?
What reduces the risk?
TX?
hemorrhage
*varices
BB to reduce risk
banding, ligation, balloon tamponade
Most common complication of cirrhosis
ascites
Portal HTN level is?
> 5
