Hepatic Biliary Systems exam 3 Flashcards
mordecai
What is cholelithiasis?
Gall stones. Hepatocytes secrete bile through bile ducts, into common hepatic duct, into gall bladder and common bile duct
Risk factors: fat pregnant female
Liver functions
Liver synthesizes glucose via _____.
Stores excess glucose as _____.
Synthesizes cholesterol and proteins into ____ and ____.
glucogenesis
glycogen
hormones and vitamins
Liver functions
Liver metabolizes fats, proteins and carbs to gerenate _____
Liver metabolizes drugs via ____ and other enzyme pathways
Liver _____ blood
energy
CYP 450
detoxifies
Liver functions
Liver is involved in the acute phase of ____ _____
Liver processes Hgb and stores ____
immune support.
iron.
Liver synthesizes all coag factors except 4. What are they?
Liver aids in volume control as a ___ _____
3, 4, 8( vWF)
blood reservoir
Liver has 8 segments. R and L lobes are separated by ____ ligament.
Where do the 3 hepatic veins empty?
Falciform (R lobe is bigger)
Right, middle and left hepatic veins empty into IVC!
Bile duct travels along ____ _____
Where does bile drain into?
How does bile enter duodenum
portal veins.
- Bile drains through the hepatic duct into gall bladder & common bile duct
- Bile enters duodenum via Ampulla of Vater
Describe O2 delivery in liver
- 50% via Portal vein (deoxygenated)
- 50% via Hepatic artery
What does portal vein arise from? How much hepatic blood flow does it supply?
Portal vein blood is deoxygenated blood from what 3 structures
portal vein arises from the splenic vein and superior mesenteric vein;makes up 75% HBF
* Portal vein blood is deoxygenated from GI organs, pancreas & spleen
What are 3 groups of hepatobiliary disease?
-hepatocellular injury (high AST/ALT)
-reduced synthetic function (low albumin, high PT/INR)
-cholestasis: high Alk phosphatase, low GGT, high bilirubin
What is choledocolithiasis?
Symtpoms?
-stone obsructing common bile duct–> biliary colic
initial: N/V, cramps, RUQ pain. Cholangitis sx: fever, rigors, jaundice
Tx: stone removal via ercp
What is ERCP?
What complication may happen?
-Endoscopics threads guidewire through sphincter of Oddi, into ampulla of vater to retrieve stone from pancreatic duct or common bile duct.
Positioning: prone w L tilt.
*May require glucagon for Oddi spasm!
What is primary biliary cholangitis aka biliary cirrhosis?
Tx?
women>
Autoimmune destruction of bile ducts with periportal inflammation and cholestasis. Leads to liver scarring, fibrosis, cirrosis.
No cure but exogenous bile acids slow progression
intrahepatic ducts only
Labs for Primary Biliary Cholangitis?
Liver biopsy reveals what?
Elevated Alk Phos, GGT and + antimitochontrial antibodies
Liver biopsy reveals bile duct destruction and infiltrations w lymphocytes
What is Wilson’s disease?
S/S?
AKA hepatolenticular degradation
-Autosomal recessive disease–> impaired copper metabolism.
-Excessive copper leads to oxidative stress in live, basal ganglia and cornea
S/S asymptomatic to sudden onset liver failure along w neurologic and psych manifestations
How is Wilson’s Disease diagnosed
serum ceruloplasmin, aminotransferases, urine copper level, liver biopsy (for Cu level)
What is the treatment of Wilson’s Disease
Treatment: copper chelation therapy and oral zinc to bind copper in GI
What is alpha-1 antitrpsin deficiency?
How is it diagnosed?
- Genetic disorder resulting in a defective α-1 antitrypsin protein
- Dx: confirmed w/ α-1 antitrypsin phenotyping
#1 cause of liver transplant in children!
α-1 antitrypsin proteins protect the liver & lungs from what?
neutrophil elastase–>enzyme that causes disruption of connective tissues, leading to inflammation, cirrhosis, and hepatocellular CA
How is alpha 1 antitrypsin deficiency treated
- Tx: pooled α-1 antitrypsin is effective for pulmonary symptoms; doesn’t help with liver disease
- Liver transplant is the only curative treatment
What is hemochromatosis?
What is the treatment
-Excess iron accumulation in body! Leads to multiorgan failure
Is genetic (excessive iron absorption) or may be caused by lots of blood transfusions or high dose iron infusions
Hemochromatosis: patients may present with what 5 conditions?
cirrhosis, heart failure, diabetes, adrenal insufficiency, or polyarthropathy
What’s the treatment for hemochromatosis?
Tx: weekly phlebotomy, iron chelating drugs, liver transplant
How is hemochromatosis diagnosed?
What are the labs?
Dx: genetic mutation testing
echo and MRI diagnose cardiomyoapthy and liver abnormalities.
Liver biopsy! may quantify iron levels and assess damage
Labs–> elevated ast/alt, transferrin saturation and ferritin
PSC
What is primary sclerosing cholangitis?
Prevalent in men in their 40’s
Autoimmune chronic inflammation of large bile ducts.
- Fibrosis in biliary tree→strictures (beads on string appearance)→ cirrhosis, ESLD
intrahepatic AND extrahepatic
How is PSC diagnosed?
beads on string*
Dx: MRCP or ERCP showing biliary strictures w dilated bile ducts
liver biopsy! but not always performed
Treatment for PSC? (primary sclerosing cholantitis?
Liver transplant! No drug treatment is effective. Reoccurence is common after transplane d/t auroimmune nature :(
What is cirrhosis? What are the symptoms
final stage of liver disease. Scarred liver!
asymptomatic in early stages. Late symptoms are jaundice, ascites, varices, coagulopathy, encephalopathy.
What are common causes of cirrhosis (4)
caused by alcoholic fatty liver, NAFL, HCV, HBV
What are the labs seen in cirrhosis?
How is it treated?
- Elevated labs: AST/ALT, bilirubin, Alk phosphatase, PT/INR
- Thrombocytopenia
Transplant is the only cure
What are complications of cirrhosis? (8)
-portal HTN (hepatic venous pressure gradient >5)
-ascites
-bacterial peritonitis
-varices
-hepatorenal syndrome
-hepatic encepalopathy
-hepatopulmonary syndrome
-portopulmonary HTN
What is ascites?
How is it managed?
Most common complication of cirrhosis.
* Portal-HTN leads to ↑blood volume & peritoneal accumulation of fluid
* Management: ↓Salt diet, albumin replacement
TIPS-reduces pulmonary HTn and ascites
What are treatment of varices?
Present in 50% cirrhosis patients
-BB help reduce risk
endoscopic banding and ligation
Balloon tamponade for bleeding
What is hepatic encephalopathy?
What is the treatment?
- Buildup of nitrogenous waste d/t poor liver detoxification
- Neuropsychiatric symptoms (cognitive impairment → coma)
Tx: Laculose, rifaximim to decrease ammonia
What is hepatorenal syndrome?
What is the treatment?
** Excess endogenous vasodilators (NO, PGs)→ decrease systemic MAP and lower RBF!
- Tx: Midodrine, Octreotide, Albumin
What is hepatopulmonary syndrome?
- Triad of chronic liver disease, hypoxemia, intrapulmonary vascular dilation
- Platypnea (hypoxemia when upright) d/t R to L intrapulmonary shunt
What is portopulmonary HTN ?
What is the treatment?
- Pulmonary HTN accompanied by portal HTN
- Systemic vasodilation triggers production of pulmonary vasoconstrictors
- Tx: PD-I’s, NO, prostacyclin analogs, and endothelin receptor antagonists
- Transplant is only cure
What are the 2 scoring systems to determine severity and prognosis of liver disease?
* Child-Turcotte-Pugh (CTP): points based on bilirubin, albumin, PT, encephalopathy, ascites
* Model for End Stage Liver Disease (MELD): score based on bilirubin, INR, creatinine, sodium
Elective surgery contradicted in what 3 diagnosis?
acute hepatitis, severe chronic hepatitis and acute liver failure
What is TIPS
Transjugular intrahepatic portosystemic shunt
-A stent/ graft placed between hepatic vein and portal vein.
-shunts blood flow to systemic circulation and reduces portosystemic pressure gradient
What are TIPS indications? (2)
Contraindications? (3)
Indications: variceal hemorrhage, regractory ascites
Cx: HF, tricuspid regurgiation and severe pulm HTN
What is partial hepatectomy?
- Resection to remove neoplasms, leaving adequate tissue for regerenation
Up to 75% removal is tolerated in patients w normal lvier!
What are anesthetic considerations in partial hepatectomy?
- Invasive monitoring
- Blood products available
- Adequate vascular access
- maintain low CVP by fluid restriction, prior to resection to reduce blood loss
-Surgeon may clamp IVC or hepatic artery to minimize blood loss
-Prepare for post op coag disturbances
-post op PCA
Intra op Managment of liver transplant ?
- Maintain hemodynamics (Pressors/Inotropes readily available)
- A-line, CVC, PA cath, TEE
- Control coagulation
Preop considerations in liver transplants?
Pre op evaluation, vascular access and blood product availability.
Intraop anesthesia considerations of liver disease?
High risk aspiration, hypotension, hypoxemia!
Plasma cholinesteraase may be decreased and NMDR will be prolonged!
Bleeding and coag managment
How does alcoholism affect MAC?
Which NMB are preffered?
Drugs onset and duration?
Alcoholism increases MAC of volatile anesthetics
Succs and cisatracurium are ideal
Drugs may have a slow onset and prolonged duration of action!
What to use for volume resuscitation in liver disease?
Colloids> crystalloids bc they are low in albumin and have low SVR
What to watch for during reperfusion of transplanted liver?
Watch for hemodynamic instability, dysrhythmias, hyperkalemia, acidosis, pulmonary emboli, and cardiac arrest
What are inborn errors of metabilism?
What are the 3 disorders?
-Groups of genetical disorders that lead to a defect in the enzymes that breakdown and store protein, carbs and fatty acids
-wilsons, alpha-1 antitrypsin deficiency and hemochromatosis`
occurs in 1:2500 births
How is non alcoholic fatty liver diasese diagnosed?
Tx?
How does it progress?
Liver biopsy; hepatocytes contain >5% fat
Tx: diet, exercise; Liver transplant indicated for advanced fibrosis and cirrhosis
Progreses to non alcoholic steatohepatitis-> cirrhosis->hepatocellular carcinoma
What’s the breakdown of oxygen delivery to the liver?
50% from portal vein (deoxygenated from GI organs, pancreas and spleen)
50% from hepatic artery
What is concerning about increased portal venous pressure?
blood backs up into systemic circ causing esophageal and gastric varices!
portal venous pressure reflects splanchnic arterial tone and intrahepatic pressure
Hepatic arterial flow is inversly related to what?
Hepatic artery dilates in response to ___________
portal venous blood flow!
dilates in response to low portal venous flow, to keep consistent hepatic blood flow
What is normal portal venous pressure?
1-5 mmHg
What portal venous pressure is considered clinically significant portal HTN (leading to cirrhosis and esophageal varices)?
> 10 mmHg
What are the most liver-specific labs?
What lab will be elevated in late stage liver damage?
AST + ALTs
gamma-glutamyl-transferase (GGT; end stage liver)
How may the AST/ALT enzymes differ between the 3 types of hepatocellular injuries?
- Acute Liver Failure: ALT/AST may be elevated 25x
- Alcoholic Liver Dz (ALD): AST:ALT ratio usually at least 2:1
- Non Alcoholic Fatty Liver Disease: ratio usually 1:1
How will you position pt for a lap chole?
reverse trendelenburg w/ a left tilt
How will you position pt for an ERCP?
prone with a left tilt, head to patient’s right, tape ETT to left
What is unconjugated bilirubin?
Protein bound to albumin, transported into liver and conjugated into its H20 soluble “direct” state, then excreted into bile
bilirubin: end product of heme breakdown
What’s the difference between unconjugated and conjugated hyperbilirubinemia?
unconjugated: imbalance between bilirubin synthesis and conjugation (think physiologic jaundice of newborns, hgb disorders, hemolysis, drug-induced, sepsis)
conjugated: caused by an obstruction that causes conjugated bili into circulation (think cholestasis, cirrhosis, congenital infections, obstructive jaundice)
What is the most common viral hepatitis requiring liver transplant in the US?
Hep C
Whats the treatment for hep C?
12 week course of sofosbuvir/velpatasvir
provides 98-99% clearance of genotype 1a/1b
What plt count requires blood transfusion?
< 50K
When do ETOH withdrawal symptoms start to occur after they stop drinking?
24-72 hours
what are some s/s of alcoholic liver disease?
malnutrition, muscle wasting, parotid gland hypertrophy (CHIPMUNK CHEEKS!), jaundice, thrombocytopenia, ascites, hepatosplenomegaly, pedal edema
What is the most common cause of drug-induced liver injury?
acetaminophen overdose
How is alcoholic disease treated?
Managment of symptoms of liver failure! Transufsion <50,000 Plt count.
-liver transfusion if criteria is met (2% of liver tx are for ALD)
What are the lab values for autoimmune hepatitis? Treatment??
+ autoantibodies and hypergammaglobulinemia
AST and ALT 10-20 times normal
Tx: steroids, azathioprine;
Immunosuppression for refractory disaease, Liver tx may be indicated
affects women; asymptomatic, acute or chronic
What are s/s of cholelithiasis?
What’s the treatment
s/s: RUQ pain referred to shoulders, N/D, indigestion, feve
Tx: IVF, antiopiotics, lap chole (reverse T w L tilt )
