50% Portal Vein (deoxygenated) 50% via Hepatic artery

Hepatic and Biliary Systems Flashcards by Rebecca Grogean

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

Liver

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What organ/system is impacted by liver function?

All
Liver dysfunction can lead to multi-organ failure

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How many segments are in the liver?

8 segments

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What seperates the Rt and Lt lobes of the Liver?

Falciform Ligmament

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

Portal Vein
Hepatic Artery

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Name (3) Hepatic veins that empty into IVC

Right Hepatic V
Middle Hepatic V
Left Hepatic V

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The____ _____ of the liver travels along portal veins?

Bile ducts

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

Gallbladder (GB)
Common Bile Duct (CBD)

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Bile enters duodenum via ______ ______ _________.

Ampulla of Vater

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

25%
1.25 - 1.5 L/min

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Which organ receives the highest CO of all the organs?

Liver

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

Portal Vein

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

Portal Vein
deoxygenated

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

Hepatic artery
Branches off the aorta

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Liver O2 delivery

50% Portal Vein (deoxygenated)
50% via Hepatic artery

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

inversely

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

Autoregulated
low

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Portal Venous pressure reflects _______ _______ tone and _______ pressure

splanchnic arterial tone
intrahepatic pressure

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

systemic
esophageal and gastric varices

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Hepatic Venous Pressure Gradient (HVPG) 1-5 mmHg

Normal portal venous pressure

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Hepatic Venous Pressure Gradient (HVPG) >10

Portal HTN
cirrhosis, esophageal varices

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Hepatic Venous Pressure Gradient (HVPG) >12

Variceal Rupture

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

Liver Dysfunction

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

Active Liver Problems

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Hepato-biliary Functions Tests Labs

* BMP, CBC * PT/INR * AST * ALT * Bilirubin * Alkaline Phosphatase * GGT

What is the most liver specific enzyme test?

ALT

Imaging to Evaluate hepato-biliary Function

* Ultrasound * Doppler U/S * CT * MRI

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

Hepatocellular Injury

Labs that indicate Hepatocellular Injury

↑AST/ALT

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

* 25x

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

* AST: ALT ratio is 2:1

Hepatobiliary disease: Reduced Synthetic Function labs

* ↓Albumin * ↑PT/INR

Hepatobiliary disease: Cholestasis labs

* ↑Alk Phosphatase * ↑GGT * ↑bilirubin

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

Cholelithiases "Gallstones"

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

* Gallbladder * Common Bile Duct

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

Cholethiasis

Symptoms of Cholelithiasis

* RUQ pain -- referred to shoulders * N/V, indigestion * Fever (acute obstructon)

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

Choleliathiasis

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

* Choledocolithiasis

_____________ is inflammation of bile duct system.

Cholangitis

Initial Symptoms of Choledocolithiasis

* N/V * Cramping * RUQ pain

Symptoms of Cholangitis

* Fever * rigors * jaundice

Cholangitis Treatment

* Endoscopic removal of stone via ERCP

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

* Endoscopic Retrograde Cholangiopancreatography

ERCP patient and ETT postioning

* pt is proned, head to the right * Tape ETT to left

Name (3) types of Hyperbilirubinemia

* Bilirubin * Unconjugated (indirect) hyperbilirubinemia * Conjugated (direct) hyperbilirubinemia

_________ is the end product of heme-breakdown

* Bilirubin

_____________ hyperbilirubinemia is the imbalance between bilirubin synthesis and conjugation. _____________ hyperbilirubinemia is caused by an obstruction, causing reflux of conjugated bilirubin into the circulation

Unconjugated (indirect) Conjugated (direct)

Name (5) types of Viral Hepatitis

* A * B * C * D * E

Name the (2) Viral Hepatitis that are more chronic

* B * C

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

* HCV

Name the Top indicator for liver transplants in US

Alcoholic Liver Disease (ALD)

Cirrhosis: Alcohol Liver Disease

* Most common cause of cirrhosis * underreported d/t stigma * intiatlly asymptomatic

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

* Abstinence * < 50,000 * Liver transplant

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

Alcoholic

When can ETOH withdrawal after someone stops drinking?

* 24-72 hr after stopping

Alcoholic Liver Disease: Lab Values

* ↑Mean corpuscular volume (MCV) * ↑Liver enzymes * ↑ɣ-glutamyl-transferase (GGT) * ↑Bilirubin * Blood ethanol (acute intox)

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

*Non-Alcoholic * > 5% fat

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

* NASH * Cirrhosis * Hepatocellular carcinoma

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

* Non-Alcoholic Fatty Liver Disease (NAFLD) * Non-Alcoholic Steatohepatitis (NASH)

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

* Liver Biopsy (gold standard)

Treatment for Non-Alcoholic Fatty Liver Disease

* Diet * Exercise * Liver transplant

Who does Autoimmune Hepatitis predominantly affect?

Women

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

Autoimmune

Treatment for Autoimmune Hepatitis

* steroids * azathioprine

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

Autoimmune

Most common cause of Drug Induced Liver Injury

* acetaminophen OD

Is Drug Induced Liver Injury reversable?

* Yes * normally reversible after drug is removed

_____________________________________ 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.

Inborn Error of Metabolism

How prevalent is inborn Errors of Metabolism?

* Occurs in 1:2,500 births

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

* neonatal * mortality.

Name (3) Specific Inborn Errors of Metabolism

* Wilson's Disease * Alpha-1 Antitrypsin Deficiency * Hemochromatosis

____________________________________ 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.

Wilsons Disease "hepatolenticular degeneration"

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

* failure * neurologic

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

*Wilsons Disease "hepatolenticular degeneration"

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

* chelation * zinc

Define Alpha-1 Antitrypsin Deficiency

* genetic disorder resultsing in a defective a-1 antitrypsin protein

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

* liver * lungs

Name the #1 genetic cause of liver transplants in children

* Alpha-1 antitrypsin Deficiency

Alpha-1 Antitrypsin Deficiency Treatments

* pooled a-1 antitrypsin effective for pulmonary symptoms * No treatment for liver.

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

* Hemochromatosis

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

* blood * iron infusions

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

Hemochromatosis

How can you diagnose Hemichromatosis?

* elevated AST/ALT * elevated transferrin saturation * elevated ferritin * genetic mutation testing * Echocardiogream and MRI * liver biopsy

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

* weekly phlebotomy * iron-chelating drugs

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

Primary Biliary Cholangitis (PBC)

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

* liver scarring * fibrosis * cirrhosis

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

* Females > Males * diagnosis in middle age * caused by exposure to enviromental toxins

Symptoms of Primary Biliary Cholangitis (PBC) aka biliary cirrhosis

* Jaundice * fatigue * itching

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

* Labs: ↑Alk Phos,↑GGT, + **Antimitochondrial antibodies** * Imaging: CT, MRI, MRCP * Liver biopsy

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

* no cure * exogenous

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

Primary Sclerosing Cholangitis (PCS)

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

Primary Sclerosing Cholangitis (PSC)

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

* Fatique * fat-soluble vitamins

Primary Sclosing Cholangitis (PSC) Labs

* ↑alkaline phosphatase and ɣ-glutamyl-transferase * +auto-antibodies

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

* MRCP or ERCP * Liver biopsy

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

Liver

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

*Re-occurrence * autoimmune

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

*Acute Liver Failure

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

* Rapid increase in AST/ALT, AMS, coagulopathy

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

Acute Liver Failure

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

Acute Liver Failure

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

* Treat the cause * supportive care * liver transplant

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

Cirrhosis

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

Cirrhosis

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

Cirrhosis

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

Cirrhosis

Cure/treatment for Cirrhosis

* Transplant is only cure

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

Portal HTN

______________ is the most common complication of cirrhosis.

* Ascites

Management of Ascites

* ↓Salt diet * albumin replacement

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

Ascites Portal- HTN

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

* Ascites * Reduces Portal-HTN

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

* cirrhosis

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

* 50% * Hemorrage

How to prevent hemorrhage due to Varices

* Beta-blockers * prophylactic endoscopic variceal banding and ligation * Refactory bleeding --> balloon tamponade

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

Hepatic Encephalopathy

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

* Lactulose * Rifaximin

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

Cirrhosis

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

Hepatorenal Syndrome

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

Hepatorenal Syndrome

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

Hepatopulmonary Syndrome

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

Portopulmonary HTN

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

* PDE-i *** Transplant is the only cure**

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

Elective

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

* Child-Turcotte Pugh (CTP) * Model for End Stage Liver Disease (MELD)

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

Child-Turcotte Purge (CTP)

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

Model for End Stage Liver Disease (MELD)

Pre-Op considerations for Liver Disease

* Careful history and physical * Standard preop labs: CBC, BMP, Pt/INR * Low threshold for invasive monitoring

Increased Risks with Anesthesia in Liver Disease

* ↑Risks aspiration * HoTN * hypoxemia

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

* colloids > crystaloids * slower onset/prolonged DoA

Alcoholism does what to the MAC of volatiles

* increases

Name (2) NMB that are ideal for Liver Disease

* Succinylcholine * Cisatracurium

Plasma cholinesterase amounts ________ in severe liver disease.

* decreased

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

* Bleeding * Coagulations

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

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

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

* Refractory variceal hemorrhage * Refractory ascites

Contraindications of TIPS

* Heart Failure * Tricuspid regurgitation * Severe pulmonary HTN

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

Partial Hepatectomy

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

* 75%

Anesthestic Considerations for a Partial Hepatectomy

* avoid invasive monitoring * blood products available * adequate vascular acess for blood/pressors

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

* IVC * hepatic artery

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

* low CVP * blood loss

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

* PCA pump

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

* preexisting liver disease and function

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

* Post -Op coagulation disturbances

What is the definitive treatment for ESLD?

* Liver transplant

Name the most common indicator for a Liver transplant?

* Alcoholic liver disease

Living Donor for Liver Transplant considerations....

* surgeries timed together * minimal ischemic time

Liver Transplant: Brain Dead Donor considerations

* keep Hemodynamics stable for organ perfusion

Intraoperative Management for Liver transplants

* Maintain Hemodynamics * A-line, CVC, PA cath, TEE * Control coagulation

Liver Transplant: Preoperative Anesthetic Considerations

* Pre-Op evaluation * vascular access * blood products available

Liver Transplant: Dissection Anesthetic Considerations

* hemodynamics compromise from loss of ascites * hemorrhage during dissection

Liver Transplant: Anhepatic Anesthetic Considerations

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