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Hepatic Flashcards

1
Q

how much blood does the liver store

A

1 L
highly vascular

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2
Q

How much does the liver weight

A

median weight of 1.8 kg in men and 1.4 kg in women.

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3
Q

Liver location

A

RUQ under rib cage = somewhat protected
hard to get exposure = steep trendelenberg

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4
Q

How much bile is produced by the gallbladder?

A

500 ml daily

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5
Q

problems with no gallbladder

A

don’t digest as well and problems in post bariatric sx and pregnant women

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5
Q

Gal bladder sythesizes ….

A

Fat
Cholesterol
Lipoproteins

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6
Q

what divides the liver?

A

falciform ligament

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7
Q

liver lobes

A

the right, left, caudate, and quadrate lobes

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8
Q

purpose of gal bladder

A

concentrate and storage for bile

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9
Q

blood supply for the gal bladder

A

cystic artery- ligated when taken out and if miss = large source of bleeding = put extra clips. X ray; kub or chest x ray will see 3-4 clips on the cycstic artery

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10
Q

cholecystitis and tx

A

inflammation of the gall bladder

tx; cholecystectomy

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11
Q

cholelithiasis and tx

A

Gallstones

tx cholecystectomy

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12
Q

choledocholithiasis and tx

A

stones in the common bile duct
- may be the result of inflammation of the pacreatic head w/ obstruct the common bile duct

tx; ERCP

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13
Q

Pain worsening with inspiration

A

murphys sign = gal bladder issues

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14
Q

Where does the majority of blood for the liver come from?

A

Portal vein

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15
Q

What percent of CO goes to the liver

A

20-30%

Average blood flow between 100-150- ml / min and. Half consumed in the liver

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16
Q

Venous drainage of liver

A

hepatic sinusoids -> central vein -> interlobar and sub lobular veins -> 3 hepatic veins -> IVC

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16
Q

Budd-Chiari syndrome

A

thrombosis of the major hepatic veins occurs

colateral blood flow through caudate veins

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17
Q

Portal htn

A

Portal vein receive blood that has already pass through the splachnic circulation

increase SVR = increase portal vein pressure

> 20-30 mmhg

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18
Q

normal portal vein pressure

A

7-10 mmhg

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19
Q

Hepatic artery perfusion pressure formula

A

Hepatic Artery Perfusion Pressure=MAP-Hepatic Vein Pressure

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20
Q

Vitamin K dependent factors

A

(2,7,9,10)

2= prothrombin

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21
Q

factors that increase hepatic blood flow

A

feeding
glucagon- dilates common bile duct
beta agonists
recumbent position
hepatocellular enzyme induction
hepatitis
hypercapnia

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22
Q

factors that decrease hepatic blood flow

A

anesthetic agents
surgical trauma
alpha agonists and beta blockers
PEEP, PPV
vasopressin - avoid boluses
hepatic cirrhosis
hypocapnia

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23
Where does bilirubin come from
Degradation product of Hgb Inc bilirubin = dec hb; causes of hb to degrade; tissue, surgery, meds = inc bili
24
Where is unconjugated bilirubin stored?
Conjugated and stored in liver Water soluble…..elimination
25
Normal billirubin levels and levels for dz processess
Normal <1mg/dL 3mg/dL ->scleral icterus >4mg/dL ->jaundice normal also; 0-11 units/L
26
Where are Aminotransferases involved?
Involved in gluconeogenesis
27
What is AST/ALT used for
Can signify hepatic injury
28
If AST/ALT BOTH elevated......
Ratio of <1: non-alcoholic liver disease; MASH Ratio of 2-4: alcoholic liver disease; Ratio of > 4: Wilson’s disease (hereditary)
29
Alkaline Phosphatase facts
Lack specificity Serum ½ life 1 week Increases…bile salt-induced damage of hepatocyte membranes
30
normal alkaline phosphate levels
30 to 100IU/L(liver and bone contributes more than 80 percent of the total value). or 45-115 units/L
31
Normal total bilirubin value
is < 1mg/dl. Out of these, up to 0.3mg is conjugated bilirubin
32
Alanine transaminase facts
Relatively liver specific Cytosol Zone 1>3 N.value O – 45 IU/L Half life is 18hrs (beneficial for acute)
33
Aspartate transaminase facts
Non specific Cytosol and mitochondria Zone 3>1 N.Value 0 – 35IU/L Half life is 36hrs
34
International Normalized Ratio increases means....
Strong correlation with declining hepatic function Impaired synthetic function of coag factors
35
Where is albumin synthesized
Synthesized by hepatocytes Impaired liver = don’t produce
36
Albumin normal value
3.5 to 5.5gm/dl. half life : 18-20 days
37
Paracentesis replacement
1;1 fluid to albmumin replaces or 1/3 of fluid removed
38
PT normal values
12-14 seconds sensitive to acute injury, prolonged by vitamin K deficiency
39
ERCP
Ampula of Vater Site of biliary obstruction Balloon dilation, sphincterotomy, stenting Multiple times -> stent = stone too big to fit through -> obstruct again
40
Encephalopathy grades
1. Changes in behavior; minimal change in LOC 2. disorientation, drowsiness, inappropriate behavior 3. marked confusion, incoherent speech, sleeping most of time 4. comatose, unresponsive to pain, decorticate/decerebrate
41
Encephalopathy exaggerated by....
infection, GI bleeding, TIPS
42
treatment for encephalopathy
decrease ammonia; lactulose and neomycin
43
Coagulopathy labs and tx
INR > 1.5- w/ no other means Tx; Vit K administration Guided replacement FFP Cryo Platelets Calcium ( with blood products as well)
44
what happens to the VOD with liver diseases
Increased volume of distribution Decreased plasma protein binding Decreased clearance of drugs
45
Treatment of cerebral edema
Head up 30 degrees - Head/neck neutral - Muscle relaxants when intubated; sedatives and muscle relaxants because difficult to actual get to sleep - Mannitol/hypertonic saline - Hyperventilation - Barbiturates coma till ICP resolves. - Treat; Lactulose
46
what is Acute Hepatitis and what causes it
Inflammation of the liver parenchyma causes by virus , hepatotoxins, autoimmune response Symptom free till late to disease…..malaise/jaundice
47
Most common cause of liver cancer and most common indication for hepatic transplant
Hepatitis
48
contraindication to elective surgery associated w/ liver
acute hepatitis
49
Hepatitis A
vaccine Common in countries without modern sanitation Lasts few weeks to months tx pooled gamma globulin
50
leading cause of liver ca an tx
Hepatitis B- Blood, sexual tx; : Hepatitis B immunoglobulin
51
Leading cause of liver transplantation
Hepatitis C (non A, non B) 50% unaware 3 out 4 1945-1965 No vaccine Parenteral drug use Treatment; interferon with ribavirin (less effective)
52
Cure for Hepatitis C
Sofosbuvir (Sovladi, Soforal)----- Inhibits HCV RNA synthesis In combo with ribavirin 12 weeks
53
Hepatitis D
Occurs in conjunction with HBV; Coinfection or superinfection
54
Hepatitis E
Oral/fecal route Transplants on immunosuppressives (for chemo or transpants) Treatment; unknown, supportive therapy leading to transplant
55
Most common cause of acute liver failure in the US
acetaminophen Overdose >4g/day
56
Halothane and hepatitis
VAA metabolized in the liver to Inorganic Fluoride and Trifluoroacetic Acid (TFA)- sticks around. Halothane produces 20%.
57
Alcoholics and elective procedures
Chronic alcoholic patient should be abstinent from alcohol for at least 6 mon to undergo elective procedure.
58
Meld score
Model of end stage liver diseases creatinine, bilirubin, INR
59
Meld score > 40
71.3% mortality
60
MELD score 10-19
6.0% mortality
61
Meld < 10
safely undergo elective surgery.
62
Meld 10 -15
may undergo elective surgery after optimization with caution.
63
Meld > 15
contraindication for elective surgery.
64
Treatment for cirrhosis
TIPS? Renal Replacement Therapy to transplantation Diuresis- get fluid out of lungs, or drainage O2 administration
65
Ammonia comes from.... and what causes it
Byproduct of nitrogen not processed out causes; Neurotoxins, GABA, oxidative stress, inflammatory mediators, hyponatremia
66
Treatment for ascites
Salt restriction Diuretics Paracentesis- replace with albumin Albumin replacement … if >5L Antibiotics- high risk sepsis/ infection
67
Most common complications leading to hospitalization
ascites
68
TIPS
Trans-jugular Intrahepatic Portosystemic Shunt bypasses a portion of the hepatic circulation by shunting blood from the portal vein to the hepatic vein This reduces portal pressure and minimizes the back pressure on the splanchnic organs thus reducing the volume of ascites and risk of varices. May also be a temporizing measure for hepatorenal syndrome
69
what kinds of drugs are more markedly affected by changes to HBF
HIGH EXTRACTION RATIO= stick around for longer Propofol Fentanyl, Morphine, Meperidine Lignocaine Verapamil Labetalol Propanolol
70
what are the metabolic functions of the liver
fat metabolism carbohydrate metabolism protein metabolism rocuronium metabolism
71
what part of the liver cleans the blood as it passes through
Kupffer cells
72
The liver performs what tasks?
gluconeogenesis forms many compounds from carbohydrate intermediaries conversion of galactose and fructose to glucose storage of large amount of glycogen
73
most common cause of cirrhosis
etoh
74
Cirrhosis results in ....
splenomegaly, esophageal varies, LHF
75
cirrhotic patients should be rescucitated with....
colloids
76
vitamin K is used to treat elevated PT which measures the ____pathway
extrinsic
77
WEPT
warfarin, extrinsic pathway, measured w/ PT
78
Plat count less than ____ requires preoperative replacement
75 K = plat before OR
79
Chronic alcoholism increases MAC for _____and this is probably due to cross tolerance
isoflurane
80
Anesthetic drugs may cause postoperative liver dysfunction to be_____
exaggerated
81
plasma cholinesterase may be _____ in severe liver disease
decreased
82
manifestation of alcohol w/d occur in ____ hours after receiving no alcohol intake
24-72 hrs
83
hepatitis A is most commonly transmitted by_____
fecal contamination
84
drugs that cause hepatitis include
analgesics VAA Anticonvulsants Tranquilizers
85
What surgical procedure is associated with the highest mortality?
Laparotomy
86
normal INR
n healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for certain disorders.

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