Hepatic Flashcards
What are the 10 functions of the Liver?
S(3)M(2) DIPSA
Synthesize glucose via gluconeogenesis
Stores excess glucose as glycogen
Synthesize cholesterol and proteins into hormones and vitamins
Metabolizes fats, proteins, carbs to generate energy
Metabolizes drugs via CYP540
Detoxifies blood
Involved in acute phase of immune System
Process hgb and stores iron
Synthesizes coag except 3,4,8 vWF)
Aids in volume control as blood reservoir
Every organ is impacted by liver function T/F
T!!!
How many anatomy segments liver?
8
Right and L lobe are separated by what
Falciform Ligament
Which hepatic veins empty into IVC
right, middle , and left hepatic veins
Bile ducts travel along
portal vein
Bile drains through
hepatic duct into gallbladder and common bile duct
Bile enters duodenum via
Ampulla of Vater
Liver perfusion is what percent?
25 percent
1.25-1.5 L per min
_____ provides partially deoxygenated blood after it has left the stomach, intestines, spleen and pancreas.
Portal vein
O2 delivery is 50 percent /50?
50 portal vein
50 hepatic artery
Where is the most hepatic blood flow
portal vein (arises from splenic and superior mesenteric vein)
75 percent!!!
Percent hepatic blood flow to hepatic artery
branches off aorta
25%!!
Portal Hypertension Patho!!
Extra info
Hepatic arterial blood flow inversely r/t to portal venous flow
Hepatic blood flow is autoregulated - hepatic artery dilates in response to low portal venous flow to keep hepatic blood flow
**Portal venous pressure reflects splanchnic arterial tone and intrahepatic pressure
increase portal venous pressure backs up into the systemic circulation causing ESOPHAGEAL AND GASTRIC VARICES
What is used to determine severity of portal hypertension?
Hepatic Venous Pressure Gradient
Normal 1-5
> 10 Portal htn, cirrhosis, & esophageal varices
> 12 VARICEAL RUPTURE
Later stages of liver only have __symstoms such as
sleep, decrease appetite
Risk Factors of Liver
Family hx
Heavy Alcohol Abuse
Lifestyle
DM
Obesity
Illicit Drug Use
Multiple Partners
Tattoos
Transfusion
Physical Exam
Pruritis
Jaundice
Ascites
***Asterixis (flapping tremors)
Hepatomegaly
Splenomegaly
SPIDER NEVI
What is the most liver specific enzyme?
ALT alamnine aminotransferase
Specific Hepato-bililary Function tests
PT/INR
AST asparate aminotransferase
Alanine aminotransferase
Bilirubin
Alkaline Phophastase
Y glutamul transferase
What are the 3 groups of hepatobiliary disease
Hepatocellular Injury
Reduced synthetic function
Cholestatsis
Types of hepatocellular injury
Acute Liver Failure
Alcoholic Liver
NAFLD
what is cholelithiasis?
Gallstones
Gallbladder stores bile to deliver during meals
CBD secretes bile directly into the duodenum
What are the risk factors of cholelithiasis
OBESITY
increased cholesterol
DM
pregnancy
female
family history
80 percent symptomatic
Cholesthiasis SS
RUQ pain going to shoulder
N/V
Fever with obstruction
Surgical and treatment for Cholelithiasis
IVF, abx, pain management
Lap Cholecystectomy (most robotic)
Choledocolithiasis Patho
Stone obstructing common bile duct –> BILIARY COLIC
Choledocolithiasis SS
orginally like cholethisiasis
**cholangitis: FRJ
Fever,rigors, jaundice
Choledocolithaisis Surgery
ERC
Endoscopic Retrograde Cholangiopancreatography
thread a guidewire through sphincter of Oddi into Ampulla Vater
Anesthetic plan for choledocolithiasis
General anesthesia
PRONE with ETT to left & turn head right
GLUCOAGON MAY BE REQUIRED INT THE EVENT ODDI SPASMS
What happens with gallstones that end up in pancreatic duct?
cause pancreatitis
What is hyperbilirubinemia?
First what is bilirubin - end product of heme breakdown
Unconjugated “indirect” bilirubin is a protein bound to albumin, transported to liver, conjugated into its H20 soluble direct state –> excreted into bile
What is the unconjugated(indirect) hyperbilirubinemia
imbalance between bilirubin synthesis and conjugation
examples
jaundice of prematurity
sepsis
drug induced
hemoglobin diorders sick cell
What is conjugated direct hyperbilirubinemia(direct)
caused by an obstruction causing reflex –> yellow
intrahepatic cholestasis
Hepatitis
cirrhosis
Dubin johson
Biliary atresia
Viral hepatitis how many types and which is the most common?
5 types
C most common but starting to be reduced due to hcv GENOTYPE 75 PERCENT TYPE 1 WITH 12 week course sofosbuvir, velpatasvir
ALD Alcoholic Liver Disease Treatment
INITIALLY ASYMPTOAMIC
ABSTIENCE
management of liver failure
**Platelet count < 50,000 —> blood transfusion
Whats the most common cause of cirrhosis/ top indicator of liver transplant (2 %_
Alcoholic Liver disease
Alcoholic Liver Disease Symptoms
asymptomatic early
Malnutition
**muscle wasting
**parotid gland hypertrophy
jaundice
thrombocytopenia *
ascities
hepatosplenomegaly
Pedal edema*
When do symptoms of etoh WITHDRAWAL occur after stoping?
24-72 hours
Lab Values with Alcoholic Liver Disease
Increase in all
Mean corpuscular volume (MCV)
Liver enzymes
Y glutamyl transferase
Bilirubin
Blood ethanol
Non- Alcoholic Fatty Liver Disease Diagnosis
Hepatocytes greater than 5 percent
Imaging and histolgy
can progress to NASH, cirrhosis, and hepatocelllular carcinoma
What is the gold standard to distinguish between NAFLD(non-alcoholic fatty liver disease) and other
Liver biopsy
What are risk factors for non-alcoholic fatty liver disease?
Obesity, insulin resistance, DM2, metabolic syndrome
RX: Diet and excercise
Transplant may be needed in extreme cases
Autoimmune Hepatitis Cause
autoantibodies and hypergammaglobulinemia
AST/ALT 20 time norm
can be asymptomatic, acute or chronic
Autoimmune heptatitis mostly affects
women
Treatment for Autoimmune heptatitis
steriods, azathiprine
60-80 remission, RELAPSE IS COMMON
Drug-Induced Liver Injury Most common cause
Acetaminophen OD
Reversible
Inborn Errors of Metabolism
defects in the enzyme breadown and store protein, carbs and fatty acids
1 in 2500 birth
**most severe in neonatal w/ high degree mortality
3 disorders of Errors of Metabolism
Wilsons Disease
Alpha 1 Antiripsin
Hemochromatosis
what is Wilsons Disease
known as HEPATOLENTICULAR DEGENERATION
**impaired copper metabolism –> excessive copper leads to oxidative stress in liver and cornea
Wilsons Disease SS
asymtpomatic to sudden onset live failure along with neuro & psych manifestations
Wilsons Disease Diagnostics
Serum ceruloplasmin, aminotransferase,urine copper level
**LIVER BIOPSY FOR COPPER Level
Wilson Disease Treatment
Copper Chelation Therapy and oral zinc to bind copper to GI tract
Alpha 1 Antitrypsin Deficiency
alpha 1 atritrypson protect the liver and lung from neutrophil elastace
What is neutrophil elastase
disruption of connective tissue, leading to inflammation, cirrhosis, and HCC
What is the #1 genetic cause of liver transplant of children
Alpha 1 Antritrypsin Deficiency
How is Antitrypsin Deficiency diagnosis
A-1 Antitrypsin phenotyping
Alpha 1 Antitrypsin Deficiency Rx
Pooled a1 antritypsin works for pulmonary but not liver
LIVER transplant can be curative
Hemochromatosis patho
excess iron leading to multi organ causing excessive intestinal absorption of iron
What can cause hemochromatosis
Repetitive blood transfusions or high dose iron infusions
EXCESS IRON
LABS FOR HEMOCHROMATOSIS
elevated AST/ALT, transferrin saturation, ferritin
Diagnosis Hemochromatosis
Genetic test
Echo and MRI for cardioypathy
Treatment for Hemochromatosis
Weekly phlebotomy, iron chelating drugs, liver transplant
Primary Biliary Cholangitis
also known as biliary cirrhosis
Patho for Primary Biliary Cholangitis
autoimmune, progressive destruction of bile ducts with periportal inflammation & cholestatsis
can lead to liver scarring
Primary Biliary Cholangitis more commin in
female middle ages
Cause Primary Biliary Cholangitis PBC
exposure to environmental toxins in genetically susceptible individuals
Primary Biliary Cholangitis labs
Increase ALK phos, GGT, antimitochondrial antibodies
Imaging Primary Biliary Cholangitis PBC
MRCP to r/o bile duct obstructions
Liver biopsy revelas bile duct destruction and infiltration w/ lymphocytes
Primary Biliary Cholangitis RX
no cure but take EXOGENOUS BILE ACIDS
can errode if diabetic or gastropersis
Primary Sclerosing Cholangitis
**AUTOIMMUNE of larger bile ducts
fibrosis in biliary tree –> stricture
more cmmon males in their 40s
Primary Sclerosing Cholangitis Labs and Symptoms
↑alkaline phosphatase andɣ-glutamyl-transferase, +auto-antibodies
S/S fatigue, itching, ** DEFICIENCY OF FAT SOLUBLE VITAMINS ADEK, cirrohosis
Primary Scelorsing Cholangitis Diagnosis Imagining
MRCP or ERCP showing biliary strictures with dilated bile ducts
BEADS ON A STRING
Primary Scelorsing Cholangitis Treatment
No treament, only long term treatment
reoccurance is common after transplant
Acute Liver Failure Patho
Life threatening severe liver injury occuring within 6 months after insult
Rapid increase AST, ALT, AMS, coagulopthaty
Acute Liver Failure is almost _% of cases drug induced by
50 percent
acetaminophen
Other causes of Acute Liver Failure
viral hepatitis, autoimmune, hypoxia, acute liver failure in pregnancy, HELLP
Acute Liver Failure Patho
Massive hepatocyte necrosis→ cellular swelling &mbrndisruption
Acute Liver Failure RX
Treat the cause, supportive care, liver transplant
Acute Liver Failure SS
Sx: Jaundice, nausea, RUQ pain, cerebral edema, encephalopathy, multi-organ failure, death
Cirrhosis
Final Stage of Liver disease
liver parenchyma replaced with scar tissue
Cirrhosis SS
progress to jaundice, ascites, varices, coagulopathy, encephalopathy
Cirrhosis Common Causes
Alcoholic fatty liver, NAFL, HCV, HBV
Cirrhosis Elevated Lab
AST/ALT, bilirubin, Alk phosphatase, PT/INR
**Thrombocytopenia
Cirrhosis ONLY CURE
transplant!!!
Cirrhosis Complications
Portal HTN - increased vascular resistance with portal venous system
Ascites - Portal HTN leads to increase in blood volume & perotineal accumulation of fluid
Spontaneous Bacterial Peritonitis
Varices **present in 50 percent
Hepatic Encephalopathy
Buildup of nitrogenous waste d/t poor liver detoxification
cognitive, coma
How to manage ascites?
decrease salt and albumin replacement
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Reduces P-HTN and ascites
What is the most common infection related to cirrhosis
Spontaneous Bacterial Peritonitis
What is the most lethal complication of cirrhosis? Interventions to combat that?
Hemmorhage from varices
Beta blockers help reduce risk
Prophylactic endoscopic variceal banding and ligation
Refractory bleeding –> balloon tamponade
Treatment for Cirrhosis Complication Hepatic enchephalopathy
Lactulose, Rifaximin to ↓ammonia-producing bacteria in gut
Cirrhosis Complications Part 2 Syndrome
Hepatorenal Syndrome
Excess endogenous vasodilators (NO, PGs)→↓systemic MAP→↓RBF
Hepatopulmonary Syndrome
Triad of chronic liver dz, hypoxemia, intrapulmonary vascular dilation
Portopulmonary HTN
Pulmonary HTN accompanied by portal HTN
Systemic vasodilation triggers production of pulmonary vasoconstrictors
How to treat Hepatorenal Syndrome r/t to complication of cirrhosis
Tx: Midodrine, Octreotide, Albumin
Hepatopulmonary Syndrome Improvement
Platypnea is a descriptive term for breathing difficulty in the upright position that improves in the supine position.
Platypnea (hypoxemia when upright) d/t R to L intrapulmonary shunt
Portopulmonary HTN
Rx related to cirrhosis
Tx: PD-I’s, NO, prostacyclin analogs, and endothelin receptor antagonists
Transplant only cure
Anesthesia Liver Disease
Elective surgery is contraindicated in which diseases
acute hepatitis, severe chronic hepatitis, and ALF
What are the 2 scoring system Scos to determine severity & prognosis of liver disease
Child-Turcotte-Pugh (CTP):points based on bilirubin, albumin, PT, encephalopathy, ascites
(BAPEA)
Model for End Stage Liver Disease (MELD): scorebased on bilirubin, INR, creatinine, sodium
(BICS)
Anesthesia in Liver Disease
↑Risks aspiration, HoTN, hypoxemia
*Colloids > crystalloids for resuscitation
Alcoholism increases MAC of volatile anesthetics
Drugs may have slow onset/prolongedDoA
Bleeding/coagulation management
Plasmacholinesterasemay be decreased in severe liver dz
What paralytics are ideal for liver disease?
Succs and Cisatracurium are ideal (not liver-metabolized)
What is Transjugular Intrahepatic Portosystemic Shunt?
a way to manage portal HTN
Stent or graft placed btw hepatic vein and portal vein
Shunts portal flow to systemic circulation
Reduces the portosystemic pressure gradient
Transjugular Intrahepatic Portosystemic Shunt Indications
Refractory variceal hemorrhage
Refractory ascites
Contraindications:
for A tranjugular Intrahepatic Portosystemic Shunt
Heart Failure
Tricuspid regurgitation
Severe pulmonary HTN
Partial Hepatectomy
Resection to remove neoplasms, leaving adequate tissue for regeneration
Anesthetic considerations:
partial hepactectomy
Invasive monitoring
Blood products available
Adequate vascular access for blood/pressors
Standard practice is to maintain low CVP by fluid restriction, prior to resection to reduce blood loss
Surgeon may clamp IVC or hepatic artery to control blood loss
Post Op Partial Hepatocteomy
Need PCA
Liver resection often causes postop coagulation disturbances
Liver Transplant
Definitive tx for ESLD
Alcoholic liver disease is the most common indication > Fatty liver, HCC
Liver Transplant
Brain dead donors
kept HD stable to for organ perfusion
Liver Transplant
Maintain hemodynamics (Pressors/Inotropes readily available)
A-line, CVC, PA cath, TEE
Control coagulation
Cholestasis
↑AlkPhosphatase,↑GGT,↑bilirubin
Reduced synthetic function:
↓Albumin, ↑PT/INR
Hepatocellular injury:
↑AST/ALT (hepatocyte enzymes)
Acute Liver Failure (ALF): may be elevated 25x
Alcoholic Liver Dz (ALD): AST:ALT ratio usually at least 2:1
NAFLD: ratio usually 1:1
