Grayson's Deck: Hepatic Diseases (Exam III) Flashcards
1
Q
How much blood is contained in the liver at any given time?
A
1L
2
Q
What positioning is often necessary to gain access to liver? (imaging, biopsy, etc.)
A
Trendelenburg
3
Q
How much bile is produced by the gallbladder daily?
A
500mls
4
Q
What is the consequence of not having a gallbladder?
A
Digestion problems
5
Q
What patient populations most often have their gallbladder removed?
A
- Pregnant
- Obese
6
Q
What anatomical feature divides the left and right lobes of the liver?
A
Falciform Ligament
7
Q
What reasons would one have for doing an open cholecystectomy vs a laparscopic cholecystecotomy?
A
- Necrotic gallbladder
- Surgeon practice (lol)
8
Q
What is the most serious source of local bleeding encountered in cholecystectomies?
A
Cystic Artery
9
Q
What are common s/s of gallbladder disease?
A
- Murphy’s sign (big deep breath in, pain will be worse in RUQ)
- RUQ pain
- ↑WBCs
10
Q
T/F. Most of the liver’s blood flow comes from the hepatic artery.
A
False. Most of the liver’s blood flow comes from the portal vein.
11
Q
What is Bud-Chiari syndrome?
What are the s/s?
A
Obstruction of the venous outflow of the liver.
- ABD pain
- Ascites
- Hepatomegaly
12
Q
What is a normal portal vein pressure?
A
7-10 mmHg
13
Q
What pressure is seen with portal vein hypertension?
A
> 20-30 mmHg
14
Q
What is a normal pressure in the venous sinusoids?
A
0 mmHg
15
Q
What pressure is seen in the venous sinusoids of a portal hypertension patient?
A
5 mmHg
16
Q
How is hepatic artery perfusion pressure calculated?
A
HAPP = MAP - HVP
HAPP = hepatic artery perfusion pressure
HVP = Hepatic vein pressure
17
Q
What blood coagulation factors are dependent on vitamin K for synthesis?
A
7, 9, 10, 2
SNOT makes you CLOT
Seven Nine 1O Two*
18
Q
What is the name of factor two?
A
Prothrombin
19
Q
What clotting factors are produced by the liver?
A
2, 3, 4, 5, 7, 8, 9, 10
20
Q
What is the name of factor 3?
A
Tissue thromboplastin
21
Q
What is the name of factor 8?
A
vWf (von Willebrand factor)
22
Q
What is the name of factor 4?
A
Calcium
23
Q
What drug is given intra-operatively that “opens up” the gallbladder?
A
Glucagon
24
Q
What factors increase hepatic blood flow?
A
- Eating
- Glucagon
- β-agonists
- Recumbent position
- Acute hepatitis
- Hypercapnia
25
What factors decrease hepatic blood flow?
- Anesthetics
- Surgical trauma
- α-agonists
- β-blockers
- PEEP
- Vasopressin boluses
- Cirrhosis
- Hypocapnia
26
This molecule is a degradation product of Hgb.
Bilirubin
27
What are normal bilirubin levels?
< 1mg/dL
28
At what bilirubin level would one see scleral icterus?
3 mg/dL
29
At what bilirubin level would one see jaundice?
>4 mg/dL
30
The liver aminotransferases are primarily involved in what?
Gluconeogenesis
31
If AST/ALT are both elevated and there is a ratio of < 1 then what is indicated?
Non-alcoholic liver disease
32
If AST/ALT are both elevated and there is a ratio of 2-4 then what is indicated?
Alcoholic liver disease
33
If AST/ALT are both elevated and there is a ratio of >4 then what is indicated?
Wilson's disease
34
What is Wilson's disease?
Inherited disorder where your body accumulates copper (especially in the liver).
35
What is the normal value of Alkaline Phosphate?
What contributes to more than 80% of the total ALP?
When is alkaline phosphatase elevated?
30 to 100 IU
Liver and Bone
When bile-salt-induced liver damage has occurred.
36
Which liver transaminase is more specific to the liver?
ALT (alanine transaminase)
37
Which liver transaminase is found in mitochondria **and** the cytosol?
AST (aspartate transaminase)
*ALT is only found in the cytosol*
38
Which of the liver transaminases has a longer half-life?
**AST (36hrs)**
ALT (18hrs)
39
What would be considered a minor increase in AST & ALT?
What would be indicated by this?
**< 100 IU**
- Hep B & C
- Non-alcoholic disease
- Fatty liver
40
What would be considered a moderate increase in AST & ALT?
What would be indicated by this?
**100 - 300 IU**
- Alcoholic hepatitis
- Autoimmune hepatitis
- Acute viral hepatitis
41
What would be considered a marked/severe increase in AST & ALT?
What would be indicated by this?
**> 300 IU**
- Drugs/Toxins
- Acute viral hepatitis
- Ischemia
- Extrahepatic cholestasis
42
AST/ALT ratio of greater than ___ but less than ______ is suggestive of cirrhosis or alcoholic liver disease.
Greater than 2, Less than 4
43
What are normal AST values?
ALT?
AST = 10 - 40 IU/L
ALT = 10 - 50 IU/L
44
What is a normal prothrombin time?
12 - 14 seconds
45
What liver lab is sensitive for acute injury?
PT (prothrombin time)
46
What liver lab is not sensitive for acute injury?
Albumin
47
What are the normal values of albumin?
3.5 - 5.0 g/dL
48
What are the four grades of encephalopathy?
Encephalopathy is exaggerated by infection and GI bleeding. What will be the only temporizing measure for these patients?
1. Behavioral changes, minimal LOC changes.
2. Disorientation, drowsiness, inappropriate behavior.
3. Marked confusion, incoherence, somnolent.
4. Comatose.
TIPS procedure
49
What are the s/s of hepatorenal syndrome?
Cause?
- H₂O retention
- Azotemia
- ↓ Na⁺ (d/t water retention)
- Oliguria
Cause: Under perfusion
50
What pharmacokinetic changes in liver patients necessitate decreases in drug dosing?
- ↑ VD
- ↓ plasma-protein binding (decease albumin level)
- ↓ drug clearance
51
How is Hepatitis A spread?
Fecal matter contact w/ food and water.
*Restaurants*
52
What are the s/s of Hep A?
Asymptomatic to acute liver failure
*Does not progress chronic disease.*
53
How is Hep A treated?
Pooled gamma globulin
54
What is the leading cause of liver cancer?
Hepatitis B
55
How is Hepatitis B spread?
- Sex
- Blood
56
Who most often develops chronic infection from hepatitis B?
Children
57
What is the treatment for Hep B?
Hepatitis B immunoglobulin
58
What is the leading cause for liver transplantation?
Hepatitis C
59
How is Hepatitis C spread?
- Sex
- Blood
- Parenteral drug use
60
How is Heptatitis C treated?
- Sofosbuvir
- Interferon w/ ribavirin
- other antivirals
61
Hepatitis D occurs in conjuction with what?
Hepatitis B
62
How is Hepatitis E spread?
- Oral/Fecal
63
What treatments exist for Hepatitis E?
NO treatments, usually self-limiting
64
What is the most common cause of acute liver failure in the US?
Acetaminophen greater than 4 g/day
65
How is acetaminophen-induced acute liver failure treated?
N-acetylcysteine within 8 hours
66
What compound(s) of halothane metabolism contributes to hepatocellular injury?
- **TFA (trifluroacetic acid)**
- Fluoride
67
Summarize all the hepatitis pathologies.
*This card is just here so I can consistently look at the graphic*.
68
What is the MELD score?
Model for End-Stage Liver Disease (predicts mortality based on symptomology).
69
A MELD score of > 40 means what?
100% mortality in the hospitalized patient.
70
A MELD score < 10 is indicative of what for a preoperative patient?
Safe to undergo elective surgery.
71
A MELD score 10-15 is indicative of what for a preoperative patient?
Needs optimization to undergo elective surgery.
72
A MELD score >15 is indicative of what for a preoperative patient?
Elective surgery is contraindicated.
**Acute hepatitis is also a contraindication to elective surgery.**
73
Cirrhosis is characterized by ____________ death.
What are the coagulative effects of cirrhosis?
**Hepatic cell death** (this means meds will stick around longer, patients will have encephalopathy d/t increased ammonia, etc.)
Clots will rapidly develop and then break down.
Impaired ability to synthesize clotting factors.
Thrombocytopenia.
Decrease levels of Protein C and Anti-thrombin III
74
What are the cardiac effects of cirrhosis?
- Portal HTN
- ↓ circulating volume
75
What are the renal effects of cirrhosis?
- Hepatorenal Syndrome
- ↑ H₂O and Na⁺ retention
76
What are the pulmonary effects of cirrhosis?
Treatments?
Chronic Lung Disease and SOB from fluid retention and ascites.
Treatments: Diuresis and give O2
77
What occurs with hepatic encephalopathy?
Accumulation of ammonia
78
Give the causes for each etiology of liver cirrhosis.
79
What is the goal Hgb for acute variceal bleeding?
Hgb = 8 mg/dL
80
What volatile is best for liver surgeries?
Sevoflurane
81
What result does hypocapnia have on hepatic blood flow?
Hypercapnia?
↓ PaCO₂ = ↓ HBF
↑ PaCO₂ = ↑ HBF
82
What portion of the clotting cascade does warfarin affect? What test measures warfarin effect?
- **W**arfarin
- **E**xtrinsic pathway
- **P**rothrombin
- **T**ime
83
Which of the following are the metabolic functions of the liver?
A. Carb Metabolism
B. Fat Metabolism
C. Protein Metabolism
D. Rocuronium Metabolism
All of the choices are correct.
The liver can metabolize all your macromolecules and muscle relaxants, with the exception of atracurium, nimbex, and Sch.
84
What part of the liver cleans the blood as it passes through?
Kupffer Cells
85
The liver performs the following:
A. Form many compounds from carb intermediaries.
B. Gluconeogenesis
C. Conversion of galactose/fructose to glucose
D. Storage of a large amount of glycogen
All of the choices are correct.
*Liver disease will cause wide spread vitamin deficiencies, hypoalbuminemia, and hypoglycemia.*
86
What is the most common cause of cirrhosis?
EtOH
87
Cirrhosis results in _______, ________, and _________.
Splenomegaly
Esophageal Varices
Right Heart Failure
88
Cirrhotic patients should be resuscitated with what kind of fluids?
Colloids (Albumin)
89
Vitamin K is used to treat an elevated PT, which measures the ________ pathway.
Extrinsic
*Warfarin Extrinsic PT, WEPT*
90
A platelet count less than ______ should receive platelets before going to the OR.
75K
91
Chronic alcoholism _____ MAC for isoflurane and this is probably due to cross-tolerance.
Increases
92
Anesthetic drugs may cause postoperative liver dysfunction to be ___________.
exaggerated
93
Plasma cholinesterase may be __________ in severe liver disease.
decreased
94
Manifestation of EtOH withdrawal occurs in ______ hours (range) after receiving no alcohol intake.
24 - 72 hours
95
Which of these drugs can cause hepatitis?
A. Analgesics
B. Anticonvulsants
C. Volatile Anesthetics
D. Tranquilizers
All choices are correct
96
What surgical procedure is associated with the highest mortality for patients with hepatic disease?
Laparotomy
97
Which Liver Function test is the most specific indicator of biliary duct obstruction? (Hint: These are the enzymes that spill into the systemic circulation)
5'-Nucleotidase
98
Medication to reduce blood ammonia levels.
Lactulose and Neomycin
99
When INR is above ___________ (not on anti-coagulation), consider giving Vitamin K.
What are some guided replacements to decrease INR?
INR above 1.5
FFP, Cryo, Plt, Calcium
100
Why are patients with liver disease considered high-risk aspiration?
Increase gastric volumes
Delayed gastric emptying
Portopulmonary Hypertension mPAP> 35 mmHg
101
What medication will not work if there is an anti-thrombin III deficiency?
What is given to increase AT-III?
Heparin
FFP
102
What can be given to treat portal hypertension?
NO
103
What is a TIPS procedure?
Trans-jugular Intrahepatic Portosystemic Shunt is a procedure to create new connections between the hepatic and portal veins to relieve pressure for late-stage liver disease.
104
Clearance of drugs with ______ hepatic extraction ratio is markedly affected by changes in hepatic blood flow.
**High hepatic extraction ratio**
High Extraction Ratio Drugs are cleared through the liver.
(Propofol, Opioids, Lidocaine, Verapamil, Beta-blockers).
This drugs will stick around longer with impaired HBF.
