Exam II Liver Biliary Disease Flashcards
Alanine transaminase (ALT).Liver enzyme for ____ breakdown. Elevated with ____ damage.
___ to ____ U/L
protein
liver
7 to 55 U/L
Aspartate transaminase (AST).Liver enzyme, metabolizes _____ ____. Increased levels may indicate liver damage, disease or _____ damage.
___ to ___ U/L
amino acids
muscle
8 to 48 U/L
Alkaline phosphatase (ALP).Liver (and bone) enzyme for protein breakdown. Increased levels may indicate liver damage or disease, blocked ____ ____ or ____ disease.
___ to ___ U/L
bile duct or bone
40 to 129 U/L
Albumin and total protein._____ synthesized in the ____. Decreased levels may indicate liver damage or disease.
Albumin:___ to ___ g/dL
Total protein:____ to ____ g/dL
protein
liver
3.5 to 5.0 g/dL
6.3 to 7.9 g/dL
Bilirubin.Produced during the normal breakdown of ____, passes through the liver, excreted in _____. Elevated bilirubin/jaundice might indicate liver damage, disease or certain types of anemia.
0.1 to ___ mg/dL (3 mg/dL leads to ____ jaundice; >4 mg/dL leads to ____ jaundice)
RBCs
stool
1.2 mg/dL
scleral
generalized
Gamma-glutamyltransferase (GGT). Liver enzyme. Increased levels may indicate ___ or ___ ___ damage.
__ to __ U/L
liver or bile duct
8 to 61 U/L
_-______ _____ (__).Liver enzyme. Elevated levels may indicate liver damage but can be elevated in many other disorders.
___ to 222 U/L
L-lactate dehydrogenase (LD)
122
Prothrombin time (PT).Increased PT may indicate ____ damage but can also be elevated with _____.
___ to ___ seconds
liver
anticoagulants
9.4 to 12.5 seconds
International normalized ratio (INR). Prolonged correlates with impaired ____function, impaired non-specific _____ and reliably predicts liver disease ____.
≤ ___
liver
coagulation
survival
1.1
Benign postoperative intrahepatic cholestasis: usually after ____ procedure, increased incidence with ____, ____, ____.
long
hypotension, hypoxia, transfusion
Benign postoperative intrahepatic cholestasis: symptoms - ____ with increased ____, other labs normal
jaundice
bili
Benign postoperative intrahepatic cholestasis: usually resolves when ____ _____ improves
underlying condition
OTHER CAUSES OF POST-OP HEPATIC DYSFUNCTION/JAUNDICE (5)
- hematoma, hemolysis, sepsis
- drug-induced
- autoimmune
Acute cholecystitis: obstructed ____ duct or ____ ____ duct leading to painful inflammation
cystic
common bile duct
Acute cholecystitis symptoms (3):
- N/V
- fever
- RUQ pain that may radiate to the back
Acute cholecystitis treatment: ____, _____, _____, or ______
IVF, opioids, cholecystectomy (usually lap), or ERCP
Acute cholecystitis: trendelenburg + insufflation = increased _____ pressure which leads to decreased _____ and decreased ___ ____
abdominal
ventilation
venous return
Acute cholecystitis: opioids may cause ___ of ____ ____
sphincter of Oddi spasm
Hepatitis:
Viral: A (50%), B (35%), C (15%), D (only seen with Hep B), HSV, CMV, Epstein-Barr
Tx: _____
Prevention: Precautions (avoid ____, get _____)
symptomatic
exposure
vaccines
Hepatitis:
Drug Induced: ____ or dose-related
Common: ______ OD leads to toxicity and necrosis
Tx: Conjugate within 8 hours with _____
idiosyncratic
acetaminophen
N-acetylcysteine
Hepatitis:
Autoimmune: No ____ treatment. Can progress to failure with need for _____.
Tx: ______ for remission
curative
transplant
corticosteroids
Hepatitis:
Halothane: Form of autoimmune hepatitis after exposure. May cross-sensitize to other agents EXCEPT _____ (d/t to its different metabolites).
sevoflurane
Hepatitis:
Chronic: ___months, usually d/t _____, progresses to cirrhosis/multi-organ dysfunction
> 6 months
ETOH
Cirrhosis:
Parenchymal liver damage with regeneration leads to ____
nodules
Cirrhosis symptoms:
F____, m____, j____, a_____, g_____, testicular ____, ascites
Fatigue, malaise, jaundice, angiectasis, gynecomastia, testicular atrophy, ascites
Cirrhosis:
increased b____, LFTs, INR, t______, h_____, decreased a_____
increased bilirubin, LFTs, INR, thrombocytopenia, hypoglycemia, decreased albumin
Cirrhosis:
fibrosis leads to increased resistance, which causes ____ _____, ascites, ____megaly, ____megaly, peripheral edema
portal HTN
hepato
spleno
Cirrhosis:
Ascites Tx: A____, low ____ diet, diuresis, p______, portosystemic shunt
Bacterial peritonitis d/t ascites has high ____&_____
albumin
sodium
paracentesis
M&M
Cirrhosis:
Portal HTN leads to ____ ____ dilatation with potential heavy bleeding.
May require intubation for airway protection and aspiration prevention.
Tx: B____, s_____, β blockers, shunt (____ vein to ____ vein)
esophageal venous
banding
sclerotherapy
hepatic
portal
Hepatic Encephalopathy
Failing liver causes ____ changes
Shunts can worsen (____/____ bypass hepatic clearance)
Tx: Low protein, drugs to ↓ ammonia absorption; avoid o____, s____, a_____
psych
ammonia/metabolites
opioids, sedatives, anesthetics
Hyperdynamic Circulation
↓ ____ with ↑ _____
Cirrhosis can lead to ______ that is difficult to manage intraoperatively.
SVR
CO
cardiomyopathy
Hepatopulmonary Syndrome
Approx. ___% of cirrhosis patients
Caused by intrapulmonary shunting, V/Q mismatch with dyspnea and hypoxia (worsens when ____)
Tx: _____
25%
upright
transplant
Portopulmonary Hypertension (____ ____ HTN + ____ ____ HTN)
<4% of cirrhosis patients but high ____ with _____ life expectancy
Tx: Prostaglandins, NO. Transplant - but only if PAP <___ mmHg
portal vein
pulmonary artery
mortality
short
45
Hepatorenal Syndrome (liver dz + renal failure)
Exact etiology unknown but probably d/t ↓ ____ and _____
Type 1 (acute) or Type 2 (chronic) – dependent on speed of onset/severity of ____ function changes
Tx: ____ ____ therapy, liver transplant
RBF
dehydration
renal
renal replacement
Coagulopathy
Most coag factors and anticoagulant proteins synthesized by liver; liver clears ____ ____ factors.
Coag function must be determined _____.
activated coag
preoperatively
Acute Liver Failure: 80-90% loss of liver function occurring in ___ ____ from appearance of 1st symptoms
< 4 weeks
Fulminant liver failure: Failure within ___ ____ of 1st symptoms
8 days
Acute Liver Failure: Mild encephalopathy causes _____ edema which leads to increased ___ and eventually ____ with high mortality
cerebral
ICP
coma
Acute Liver Failure causes: _____ OD, ____ reaction, hepatitis, acute ____ liver of pregnancy, _____ dz, _____ syndrome
acetaminophen
drug
fatty
Wilson’s
Reye’s
Acute Liver Failure Tx: Management of coagulopathies, renal failure, respiratory complications, metabolic abnormalities
Newer intervention: “___ ___”, Caution: ____ monitoring with coagulopathy
liver dialysis
ICP
Acute Liver Failure: Without transplant, ___ ___. After transplant, ___ ___.
85% die
65% die
____ of liver damage + type of _____ = perioperative risk
degree
surgery
____-____ score for severity classification (5 variables. See Table 17.6, p. 354.)
Child-Pugh
Nutrition/Metabolic
Pts are m______, v____ deficient, ↓ albumin, hypo_____, hyponatremia (with ↑ total body Na+), have altered drug metabolism.
malnourished
vitamin
hypoglycemic
Encephalopathy
May or may not be relational to ____ damage
Investigate new onset ____ symptoms.
Preoperative encephalopathy = ↑ ____ & _____ risks
liver
neuro
surgical & anesthesia
Pulmonary
Hepatopulmonary Syndrome? Portopulmonary HTN? Aspiration risk? Room air saturation? PFTs? PAP?
_____ = full stomach/delayed emptying with need for RSI
Ascites
Renal
Hepatorenal syndrome
Beware of ↑ _____/↓ clearance and metabolic _____
B____, hypo____, nephrotoxic drugs increase risk
creatinine
acidosis
bleeding, hypotension
Circulation
↓ ____ partially compensated with ↑ ____.
↓ ____ causes interstitial edema
SVR
CO
albumin
Consider ___ ___, foley, pressors. _____, ____, and ____ common for transplants.
art line
phenylephrine, norepi, and vasopressin
Coagulopathy
Thromboelastography (TEG®, ROTEM®) may be useful. Consider vitamin ____ with _____.
K
malnutrition
Coagulopathy
Consider targeted ___, _____, ____ transfusions.
Citrate may not be metabolized. May need ____ treatment.
FFP, cryoprecipitate, platelets
Ca++
Drug Metabolism
Affected by impaired liver metabolism, ↑ ___, ↓ ____ binding, ↓ ____.
Consider ______ class (metabolized without liver enzymes).
Vd
protein
clearance
benzylisoquinoline
Postoperative
Most common cause of cirrhosis patient death: ___ ___
To ICU immediately post-op
liver failure
liver transplant
>6,700 in U.S./year; >12,000 waiting; >56,000 in U.S. with transplanted liver
Most common disease: ____ ____
hepatitis C
liver transplant
>90% are _____
cadaveric
liver transplant
Peds: Lobe of liver has _____ results
Adults: Size-mismatching (small for size syndrome) is _____.
excellent
problematic
liver transplant
Best results: Donor liver at least as ____ as native liver
large
liver transplant
Former contraindications: A_____, chronic hepatitis (especially ___) and ____. Now most frequent indications.
alcoholism
C
cancer
liver transplant
Model End-Stage Liver Disease (MELD) scores predict mortality probability within ___ ____ with ____ ____. MELD scores determine waiting list rankings.
90 days
NO transplant
liver transplant
For ___ ___, Milan staging criteria used.
liver cancer
transplant procedure 3 stages
1 dissection
2 anhepatic
3 reperfusion
phase 1 dissection - Immobilizing vascular structures and native liver removal leading to _____ with ______ instability
hemorrhage
hemodynamic
phase 2 Anhepatic – Hepatic artery and portal vein clamped; venovenous bypass used. Retractors cause decreased _____/_____. No liver function leads to ____ _____, ↓ drug metabolism, ____ toxicity. Ca++ often needed.
ventilation/oxygenation
metabolic acidosis
citrate
phase 3 - Reperfusion (neohepatic) – After anastomosis of donor liver. Vascular _____ (reperfusion) leads to CV instability, d_____, b_____, hypo_____, hyper______ (highest risk phase).
unclamping
dysrhythmias
bradycardia
hypotension
hyperkalemia
Drug metabolism resumes after ______.
reperfusion
Coag factors given to normalize clotting. With good perfusion, ____ improve, _____ ____ reverses, oxygenation improves.
(Reperfusion/Neohepatic)
LFTs
hyperdynamic circulation
___-_____ now being done in some transplant centers.
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