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Health Assessment Exam 3 > Hepatic and Biliary Systems > Flashcards

Hepatic and Biliary Systems Flashcards

1
Q

The Following are the functions for what organ?

  • Synthesize glucose
  • stores glucose
  • synthesizes cholesterol and proteins into hormones and vitamins
  • metabolizes fat, proteins and carbs
  • metabolizes drugs via CYP-540
  • Detoxifies blood
  • involved in acute phase of immune support
  • Processs HGB and stores iron
  • synthesizes coagulations factors
  • Aids in volume control as a blood resevoir
A

Liver

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2
Q

What organ/system is impacted by liver function?

A
  • All
  • Liver dysfunction can lead to multi-organ failure
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3
Q

How many segments are in the liver?

A
  • 8 segments
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4
Q

What seperates the Rt and Lt lobes of the Liver?

A
  • Falciform Ligmament
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5
Q

The _____ vein and _____ artery branch into each segment of the Liver?

A
  • Portal Vein
  • Hepatic Artery
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6
Q

Name (3) Hepatic veins that empty into IVC

A
  • Right Hepatic V
  • Middle Hepatic V
  • Left Hepatic V
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7
Q

The____ _____ of the liver travels along portal veins?

A

Bile ducts

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8
Q

Bile drains through the Hepatic Duct into the ________ and ______ Bile Duct.

A
  • Gallbladder (GB)
  • Common Bile Duct (CBD)
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9
Q

Bile enters duodenum via ______ ______ _________.

A
  • Ampulla of Vater
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10
Q

The liver receives _% of CO, or _-__ L/min.

A
  • 25%
  • 1.25 - 1.5 L/min
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11
Q

Which organ receives the highest CO of all the organs?

A
  • Liver
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12
Q

What vein arises from the splenic vein and superior mesenteric vein?

A

Portal Vein

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13
Q

The _______ vein provides 75% of Hepatic blood and is _________________ by the GI organs, pancreas and spleen.

A
  • Portal Vein
  • deoxygenated
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14
Q

The __________ artery provides 25% of Hepatic blood flow and branches off the _________.

A
  • Hepatic artery
  • Branches off the aorta
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15
Q

Liver O2 delivery

A
  • 50% Portal Vein (deoxygenated)
  • 50% via Hepatic artery
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16
Q

Hepatic Artery blood flow is ________ r/t portal venous blood flow.

A

inversely

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17
Q

hepatic blood flow is _________ and hepatic artery dilates in reponse to ____ portal venous flow.

A
  • Autoregulated
  • low
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18
Q

Portal Venous pressure reflects _______ _______ tone and _______ pressure

A
  • splanchnic arterial tone
  • intrahepatic pressure
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19
Q

Portal Hypertension (↑Portal venous pressure) causes blood to back up into _________ circulation and causes ________ and _________ varices

A
  • systemic
  • esophageal and gastric varices
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20
Q

Hepatic Venous Pressure Gradient (HVPG) 1-5 mmHg

A
  • Normal portal venous pressure
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21
Q

Hepatic Venous Pressure Gradient (HVPG) >10

A
  • Portal HTN
  • cirrhosis, esophageal varices
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22
Q

Hepatic Venous Pressure Gradient (HVPG) >12

A
  • Variceal Rupture
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23
Q

Below are Risk Factors for _______________.
* Family hx
* Heavy ETOH
* Lifestyles
* DM
* Obesisty
* Illicit Drug use
* Multiple Partners
* Tattoos
* Transfusions

A

Liver Dysfunction

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24
Q

These Physical Exam findings indicate__________.
* Pruritis
* jaundice
* Ascites
* Asterixis (flapping tremor)
* Hepatomegaly
* Splenomegaly
* Spider nevi

A

Active Liver Problems

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25
Q

Hepato-biliary Functions Tests Labs

A
  • BMP, CBC
  • PT/INR
  • AST
  • ALT
  • Bilirubin
  • Alkaline Phosphatase
  • GGT
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26
Q

What is the most liver specific enzyme test?

A

ALT

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27
Q

Imaging to Evaluate hepato-biliary Function

A
  • Ultrasound
  • Doppler U/S
  • CT
  • MRI
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27
Q

Acute Liver Failure, Alcoholic Liver Disease and Non-Alcoholic Liver Disease are all causes of ____________.

A

Hepatocellular Injury

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27
Q

Labs that indicate Hepatocellular Injury

A

↑AST/ALT

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28
Q

AST/ALT will be elevated ____ x in Acute Liver Failure (ALF)

A
  • 25x
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29
Q

In Alcoholic Liver dz, ___:___ ration is 2:1

A
  • AST: ALT ratio is 2:1
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30
Q

Hepatobiliary disease: Reduced Synthetic Function labs

A
  • ↓Albumin
  • ↑PT/INR
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31
Q

Hepatobiliary disease: Cholestasis labs

A
  • ↑Alk Phosphatase
  • ↑GGT
  • ↑bilirubin
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32
Q

_________________ is caused by hepatocytes secreting bile through ducts, into common hepatic duct and into Gallbladder and Common bile duct

A

Cholelithiases “Gallstones”

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33
Q

The _________ stores bile to deliver during meals
____________ duct secretes bile directly into duodenum.

A
  • Gallbladder
  • Common Bile Duct
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34
Q

Obesity, high cholesterol, DM, pregnancy, female, and family history are all common risk factors of ______________.

A

Cholethiasis

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35
Q

Symptoms of Cholelithiasis

A
  • RUQ pain – referred to shoulders
  • N/V, indigestion
  • Fever (acute obstructon)
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36
Q

IVF, antibiotics, pain management and Lap Cholecystectomy are treatment for _______________.

A

Choleliathiasis

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37
Q

________________ is a stone obstructions ofthe common bile duct that can lead to biliary colic.

A
  • Choledocolithiasis
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38
Q

_____________ is inflammation of bile duct system.

A

Cholangitis

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38
Q

Initial Symptoms of Choledocolithiasis

A
  • N/V
  • Cramping
  • RUQ pain
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39
Q

Symptoms of Cholangitis

A
  • Fever
  • rigors
  • jaundice
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40
Q

Cholangitis Treatment

A
  • Endoscopic removal of stone via ERCP
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41
Q

Below is the surgical overview for what procedure?
* Endoscopist threads guidewire through Sphincter of Oddi, into Ampulla of Vater to retrieve stone from pancreatic duct or CBD
* GA, usually prone w/left tilt (tape ETT to left)
* Glucagon may be required in the event of Oddi Spasm

A
  • Endoscopic Retrograde Cholangiopancreatography
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42
Q

ERCP patient and ETT postioning

A
  • pt is proned, head to the right
  • Tape ETT to left
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43
Q

Name (3) types of Hyperbilirubinemia

A
  • Bilirubin
  • Unconjugated (indirect) hyperbilirubinemia
  • Conjugated (direct) hyperbilirubinemia
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44
Q

_________ is the end product of heme-breakdown

A
  • Bilirubin
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45
Q

_____________ hyperbilirubinemia is the imbalance between bilirubin synthesis and conjugation.

_____________ hyperbilirubinemia is caused by an obstruction, causing reflux of conjugated bilirubin into the circulation

A

Unconjugated (indirect)

Conjugated (direct)

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46
Q

Name (5) types of Viral Hepatitis

A
  • A
  • B
  • C
  • D
  • E
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47
Q

Name the (2) Viral Hepatitis that are more chronic

A
  • B
  • C
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48
Q

Name the most common viral hepatitis requiring liver tranplant in the US.

A
  • HCV
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49
Q

Name the Top indicator for liver transplants in US

A

Alcoholic Liver Disease (ALD)

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50
Q

Cirrhosis: Alcohol Liver Disease

A
  • Most common cause of cirrhosis
  • underreported d/t stigma
  • intiatlly asymptomatic
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51
Q

Treatment of Alcoholic Liver Disease includes ________ , management of symptoms, transfusion for platelets < ___________ and a liver ________.

A
  • Abstinence
  • < 50,000
  • Liver transplant
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52
Q

Symptoms of _____________ Liver Disease include:
* Malnutrition
* muscle wasting
* Parotid gland hypertrophy
* Jaundice
* thrombocytopenia
* ascites
* Hepatosplenomegaly
* Pedal Edema

A

Alcoholic

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53
Q

When can ETOH withdrawal after someone stops drinking?

A
  • 24-72 hr after stopping
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54
Q

Alcoholic Liver Disease: Lab Values

A
  • ↑Mean corpuscular volume (MCV)
  • ↑Liver enzymes
  • ↑ɣ-glutamyl-transferase (GGT)
  • ↑Bilirubin
  • Blood ethanol (acute intox)
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55
Q

____________ Fatty Liver Disease is on the rise in the US and is diagnosied when hepatocytes contain > ___% fat

A

*Non-Alcoholic
* > 5% fat

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56
Q

Name (3) disease processes that Non-Alcoholic Fatty Liver Disease progresses to

A
  • NASH
  • Cirrhosis
  • Hepatocellular carcinoma
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57
Q

Besides Alcohol Liver Disese, what (2) disease processes are becoming additional causes of liver transplants in the US?

A
  • Non-Alcoholic Fatty Liver Disease (NAFLD)
  • Non-Alcoholic Steatohepatitis (NASH)
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58
Q

______ _______ is the gold standard of diagnosis of Non-Alcoholic Fatty Liver Disease, in addition to imaging and histology.

A
  • Liver Biopsy (gold standard)
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59
Q

Treatment for Non-Alcoholic Fatty Liver Disease

A
  • Diet
  • Exercise
  • Liver transplant
60
Q

Who does Autoimmune Hepatitis predominantly affect?

61
Q

Postive autoantibodies, hypergammaglobulinemia and AST/ALT 10-20 x normal can diagnose ____________ Hepatitis.

A

Autoimmune

62
Q

Treatment for Autoimmune Hepatitis

A
  • steroids
  • azathioprine
63
Q

Transplant indicated for ____________ Hepatitis when treatments fail and acute liver failure ensues.

A

Autoimmune

64
Q

Most common cause of Drug Induced Liver Injury

A
  • acetaminophen OD
65
Q

Is Drug Induced Liver Injury reversable?

A
  • Yes
  • normally reversible after drug is removed
66
Q

_____________________________________ is a group of rare, genetically inherited disorderes that lead to a defect in the enzymes that breakdown and store protein, carbohydrates and fatty acids.

A

Inborn Error of Metabolism

67
Q

How prevalent is inborn Errors of Metabolism?

A
  • Occurs in 1:2,500 births
68
Q

The most severe form of Inborn Error of Metabolism Occur in the _______ period cause a ______ degree of mortality.

A
  • neonatal
  • mortality.
69
Q

Name (3) Specific Inborn Errors of Metabolism

A
  • Wilson’s Disease
  • Alpha-1 Antitrypsin Deficiency
  • Hemochromatosis
70
Q

____________________________________ is an autosomal recessive disease characterized by impaired copper metabolism. The excessive copper buildup leads to oxidative stress in the liver, basal ganglia and cornea.

A

Wilsons Disease “hepatolenticular degeneration”

71
Q

Wilsons Disease “hepatolenticular degeneration” symptoms can be asymptomatic to sudden onset of liver _____ and has ________ and psychiatric manifestations.

A
  • failure
  • neurologic
72
Q

____________________ is diagnosed with:
* serum ceruloplasmin
* amiotransferase
* urine copper level
* Liver biopsy for copper level

A

*Wilsons Disease “hepatolenticular degeneration”

73
Q

Wilsons Disease “hepatolenticular degeneration”is treated with Copper - ______ therapy and oral ________ to bind copper in GI tract.

A
  • chelation
  • zinc
74
Q

Define Alpha-1 Antitrypsin Deficiency

A
  • genetic disorder resultsing in a defective a-1 antitrypsin protein
75
Q

Alpha-1 antitrypsin protects the _____ and ______ from neutrophil elastase.

A
  • liver
  • lungs
76
Q

Name the #1 genetic cause of liver transplants in children

A
  • Alpha-1 antitrypsin Deficiency
77
Q

Alpha-1 Antitrypsin Deficiency Treatments

A
  • pooled a-1 antitrypsin effective for pulmonary symptoms
  • No treatment for liver.
78
Q

______________ is excess iron in the body that leads to multi-organ dysfunction. It may be genetic.

A
  • Hemochromatosis
79
Q

Hemochromatosisis caused by genetics, repetative ________ transfusions and high-dose _________ infusions.

A
  • blood
  • iron infusions
80
Q

Cirrhosis, heart failure, diabetes, adrenal insufficiency and polyarthropathy are all presentations of ________________ .

A

Hemochromatosis

81
Q

How can you diagnose Hemichromatosis?

A
  • elevated AST/ALT
  • elevated transferrin saturation
  • elevated ferritin
  • genetic mutation testing
  • Echocardiogream and MRI
  • liver biopsy
82
Q

Hemochromatosisis treated with _________ phlebotomy, iron-______ drugs and liver transplant.

A
  • weekly phlebotomy
  • iron-chelating drugs
83
Q

_____ ______ cholangitis aka biliary cirrhosis is an autoimmune, progressive destruction of bile ducts with periportal inflammation and cholestasis.

A

Primary Biliary Cholangitis (PBC)

84
Q

Primary Biliary Cholangitis (PBC)
aka biliary cirrhosis can lead to

A
  • liver scarring
  • fibrosis
  • cirrhosis
85
Q

Primary Biliary Cholangitis (PBC)
aka biliary cirrhosis primarily affect ______, is diagnosed in _________ age, and caused by exposure to _______ toxins.

A
  • Females > Males
  • diagnosis in middle age
  • caused by exposure to enviromental toxins
86
Q

Symptoms of Primary Biliary Cholangitis (PBC)
aka biliary cirrhosis

A
  • Jaundice
  • fatigue
  • itching
87
Q

How can you diagnosis Primary Biliary Cholangitis (PBC)
aka biliary cirrhosis

A
  • Labs: ↑Alk Phos,↑GGT, + Antimitochondrial antibodies
  • Imaging: CT, MRI, MRCP
  • Liver biopsy
88
Q

There is no ____ for Primary Biliary Cholangitis, but _____ bile acid and slow progression.

A
  • no cure
  • exogenous
89
Q

_______ _________ _______ is an autoimmune, chronic inflammation of larger bile ducts. Can be Intrahepatic and extrahepatic.

A

Primary Sclerosing Cholangitis (PCS)

90
Q

This is caused by:
* Fibrosis in biliary tree→strictures (beads on string appearance)→ cirrhosis, ESLD
* Males > females, onset 40s.

A

Primary Sclerosing Cholangitis (PSC)

91
Q

Symptoms of Primary sclerosing Cholangitis (PSC) include ______, itching, deficiency of ____ - soluble vitamins and cirrhosis.

A
  • Fatique
  • fat-soluble vitamins
92
Q

Primary Sclosing Cholangitis (PSC)
Labs

A
  • ↑alkaline phosphatase and ɣ-glutamyl-transferase
  • +auto-antibodies
93
Q

Diagnosis of Primary Sclerosing Cholangitisis done by a ____ or _____ showing biliary stricture w dilated bile ducts and a _____ biopsy.

A
  • MRCP or ERCP
  • Liver biopsy
94
Q

___________ transplant is the only long term treatment of Primary Sclerosing Cholangitis (PSC). No drug therapy is currently effective.

95
Q

____________of Primary Sclerosing Cholangitis (PSC) is common after transplant d/t _____________ nature.

A

*Re-occurrence
* autoimmune

96
Q

__________________ is a life-threatening severe liver injury occuring within days to 6 months after insult.

A

*Acute Liver Failure

97
Q

Acute Liver Failure Lab work will show a _____ ______ in AST/ALT, AMS and coagulopathy.

A
  • Rapid increase in AST/ALT, AMS, coagulopathy
98
Q

The following are all causes of ______________:
* 50% cases are drug induced (tylenol OD)
* Viral hepatitis
* autoimmune
* hypoxia
* ALF of Pregnancy
* HELLP

A

Acute Liver Failure

99
Q

Symptoms of ______________________:
* Jaundice
* nausea
* RUQ pain
* cerebral edema
* encephalopathy
* multiorgan failure death

A

Acute Liver Failure

100
Q

Treatment for Acute Liver failure includes treating the ________, and _________ care. If that fails, the only other treatment is a Liver ___________.

A
  • Treat the cause
  • supportive care
  • liver transplant
101
Q

______________ is the final stage of liver disease. Normal liver parenchyma replaced with scar tissue.

102
Q

Symptoms of _____________:
* Asymptomatic in early stages
* jaundice
* ascites
* varices
* coagulopathy
* encephalopathy

103
Q

Alcoholic fatty liver, Non-Alcoholic fatty liver, NCV and HBV are all common causes of ____________.

104
Q

Elevated AST/ALT, bilirubin, Alk phopshate, PT/INR, and thrombocytopenia can all indicate_______________.

105
Q

Cure/treatment for Cirrhosis

A
  • Transplant is only cure
106
Q

_________________ is increased vascular resistance within the portal venous system with an HVPG > 5.

A

Portal HTN

107
Q

______________ is the most common complication of cirrhosis.

108
Q

Management of Ascites

A
  • ↓Salt diet
  • albumin replacement
109
Q

_________________ leads to increased blood volume and peritoneal accumulation of fluid.

A

Ascites Portal- HTN

110
Q

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is the surgical management of ____________ and reduces _____- HTN

A
  • Ascites
  • Reduces Portal-HTN
111
Q

Spontaneous Bacterial Peritonitisis the most common infection r/t ___________ and requires antibiotics

112
Q

Varices present in ___% of cirrhosis patients. _______ is the most lethal complication.

A
  • 50%
  • Hemorrage
113
Q

How to prevent hemorrhage due to Varices

A
  • Beta-blockers
  • prophylactic endoscopic variceal banding and ligation
  • Refactory bleeding –> balloon tamponade
114
Q

____________________- is the buildup of nitrogenous waste d/t poor liver detoxification and can cause Neuropsychiatric symptoms (cognitive impairment → coma)

A

Hepatic Encephalopathy

115
Q

Hepatic Encephalopathyis treated with _____ and ______ to ↓ammonia-producing bacteria in gut

A
  • Lactulose
  • Rifaximin
116
Q

Hepatorenal Syndrome, hepatopulmonary syndrome and portopulmonary HTN are (3) ____________ Complications

117
Q

____________________ causes release of endogenous vasodilators (NO, PGs) →↓systemic MAP→↓RBF

A

Hepatorenal Syndrome

118
Q

Midodrine, Octreotide and albumin are all used to Treat ___________________.

A

Hepatorenal Syndrome

119
Q

_____________ Syndrome is a triad of chronic liver disease, hypoxemia, intrapulmonary vascular dilation. With platypnea (hypoxemia when upright) d/t Rt to Lt intrapulmonary shunt.

A

Hepatopulmonary Syndrome

120
Q

________________________ HTN is accompanied by portal HTN. Systemic vasodilation triggers production of pulmonary vasoconstrictors.

A

Portopulmonary HTN

121
Q

Treatment of Portopulmonary HTN includes _____ - inhibitors, NO, Prostacycline analogs and endothelium receptors antagonists. __________ is the only cure.

A
  • PDE-i

* Transplant is the only cure

122
Q

____________ surgery is contraindicated in acute hepatisis, severe chronic hepatitis and ALF.

123
Q

Name the (2) Scoring systems to determine severity and prognosis of liver disease

A
  • Child-Turcotte Pugh (CTP)
  • Model for End Stage Liver Disease (MELD)
124
Q

This scoring system of Liver disease has
points based on bilirubin, albumin, PT and encephalopathyon.

A

Child-Turcotte Purge (CTP)

125
Q

This scoring system of Liver disease score is based on bilirubin, INR, creatine and sodium.

A

Model for End Stage Liver Disease (MELD)

126
Q

Pre-Op considerations for Liver Disease

A
  • Careful history and physical
  • Standard preop labs: CBC, BMP, Pt/INR
  • Low threshold for invasive monitoring
127
Q

Increased Risks with Anesthesia in Liver Disease

A
  • ↑Risks aspiration
  • HoTN
  • hypoxemia
128
Q

For Anesthesia in Liver Disease, ____ > _____ for fluids and drugs many have a _____ onset/prolonged DoA.

A
  • colloids > crystaloids
  • slower onset/prolonged DoA
129
Q

Alcoholism does what to the MAC of volatiles

130
Q

Name (2) NMB that are ideal for Liver Disease

A
  • Succinylcholine
  • Cisatracurium
131
Q

Plasma cholinesterase amounts ________ in severe liver disease.

132
Q

What (2) things do you have to manage in Liver patients to prevent complications

A
  • Bleeding
  • Coagulations
133
Q

__________________________ procedure is a stent or graft placed btw hepatic veins and portal veins. Shunts portal flow to systemic circulation and reduces portosymstemic pressure gradient.

A

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

134
Q

Refactory ________ hemorrhage and Refactory _________ are indications for Transugular Intrahepatic Portosystemic Shunt

A
  • Refractory variceal hemorrhage
  • Refractory ascites
135
Q

Contraindications of TIPS

A
  • Heart Failure
  • Tricuspid regurgitation
  • Severe pulmonary HTN
136
Q

________________ is a resection to remove neoplasma, leaving adequate tissue for regeneration.

A

Partial Hepatectomy

137
Q

Up to ____% removal of the liver is tolerated in pts with normal liver function.

138
Q

Anesthestic Considerations for a Partial Hepatectomy

A
  • avoid invasive monitoring
  • blood products available
  • adequate vascular acess for blood/pressors
139
Q

In a Partial Hepatectomy, what might the surgeon clamp the_____ and _______ to control blood loss?

A
  • IVC
  • hepatic artery
140
Q

Standard practice for a Partial Hepatectomy is to maintain ____ CVP by fluid restriction prior to resection to reduce _______ ________.

A
  • low CVP
  • blood loss
141
Q

What will patient’s require after Partial Hepatectomy for adequate pain control?

142
Q

In a partial Hepatectomy, what determines the tolerable amount of resection?

A
  • preexisting liver disease and function
143
Q

Whare are some post-op complications for Partial Hepatectomy of liver resection?

A
  • Post -Op coagulation disturbances
144
Q

What is the definitive treatment for ESLD?

A
  • Liver transplant
145
Q

Name the most common indicator for a Liver transplant?

A
  • Alcoholic liver disease
146
Q

Living Donor for Liver Transplant considerations….

A
  • surgeries timed together
  • minimal ischemic time
147
Q

Liver Transplant: Brain Dead Donor considerations

A
  • keep Hemodynamics stable for organ perfusion
148
Q

Intraoperative Management for Liver transplants

A
  • Maintain Hemodynamics
  • A-line, CVC, PA cath, TEE
  • Control coagulation
149
Q

Liver Transplant: Preoperative Anesthetic Considerations

A
  • Pre-Op evaluation
  • vascular access
  • blood products available
150
Q

Liver Transplant: Dissection Anesthetic Considerations

A
  • hemodynamics compromise from loss of ascites
  • hemorrhage during dissection
151
Q

Liver Transplant: Anhepatic Anesthetic Considerations

A

**HD compromise: **
* IVC clamping
* metabolic acidosis
* hypocalcemia from citrate intoxication
* hyperkalemia
* hypothermia
* hypoglycemia

Health Assessment Exam 3 (5 decks)

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