Hepatic Disease Flashcards
• Largest internal organ; located in the R upper quadrant
• Dual blood supply
➢ ~ 20 % Hepatic artery - oxygenated blood
➢ 80% Portal vein –nutrients
Liver
- left and right hepatic ducts forms the _________
- drains bile from the liver
- transports waste from the liver and aids in digestion by releasing bile
common hepatic duct
- carries bile from the liver and the gallbladder through the pancreas and into the
duodenum - part of the biliary duct system; formed where the ducts from the liver and gallbladder are
joined
Common bile duct
– drain venous blood from liver to inferior vena cava and on to the right
Hepatic Veins
– provides oxygen and nutrition to liver tissues
Hepatic Artery
– delivers substances absorbed by the gastrointestinal tract (stomach,
intestine, spleen and pancreas) for metabolic conversion and/or removal in the liver
Hepatic Portal Vein
Functions of \_\_\_\_\_\_\_: ➢ Synthesizes proteins - Immunoglobulins - Albumin - coagulation factors - carrier proteins - growth factors - hormones ➢ Synthesizes bilirubin ➢ Produces bile and cholesterol ➢ Regulates nutrients - glucose - glycogen - lipids - amino acids ➢ Prepares drugs for excretion ➢ Responsible for drug conjugation and metabolism oPhase I –cytochrome P450; can produce toxic metabolites oPhase II –conjugation (glucuronidation, sulfation, inactivation by glutathione, etc.)
Hepatocytes
Signs of \_\_\_\_\_; ➢ Jaundice ➢ Ascites (backup of drainage) ➢ Edema ➢ GI bleed ➢ Dark urine ➢ Light stool ➢ Mental confusion ➢ Xanthelasma (Improper storage of cholesterol) ➢ Spider angiomas ➢ Palmar erythema ➢ Asterixis ➢ Hyperpigmentation
Liver disease
Symptoms of \_\_\_\_\_\_\_: ➢ Appetite loss ➢ Bloating ➢ Nausea ➢ RUQ pain ➢ Fatigue ➢ Mental confusion
Liver disease
___ is a sign of current or past liver disease
- Deposits of cholesterol around the eyes
Xanthelasma
- a.k.a. flapping tremor
- classic sign in hepatic encephalopathy (HE)
- jerky movements when hands are extended at wrists.
Asterixis
______ is a syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in pts with severe liver disease
- can be a chronic problem in pts with cirrhosis, managed medically to varying degrees of success, puntuated with occasional exacerbations
- these acute exacerbations are rarely fatal
Hepatic Encephalopathy (HE)
• evaluate the cells that circulate in blood red blood cells (RBCs) white blood cells (WBCs) platelets (PLTs) • indicator of overall health • may detect a variety of diseases and conditions - infection - anemia - leukemia - lymphoma - neutropenia - etc.
Complete blood count (CBC)
• aka chemical screen or,
SMAC 14 (Sequential Multiple Analysis –Computer)
• consists of 14 blood tests which serves as an initial broad medical screening tool
• Includes
- General tests
- Kidney function assessment
- Electrolytes
- Protein tests
- Liver function assessment
• there are also SMAC 8, 12, 16 and 20 variants
Comprehensive Metabolic Panel (CMP)
What is the most common Comprehensive Metabolic Panel (CMP) used?
SMAC 14
___ are the most important liver proteins that are used as carriers of nutrients in blood
Albumin
oProduct of heme breakdown
oIncreased total bilirubin, increased severity of liver injury
➢ Bilirubin (high)
Is unconjugated or conjugated bilirubin harder to detect?
Unconjugated
______ bilirubin
❖Insoluble, bound to albumin, not filtered by kidney
❖Increased SERUM not really indicative of liver disease,
❖indicates hemolysis, ineffective erythropoiesis (thalassemia,
vitamin B deficiency, Gilbert syndrome)
Unconjugated (indirect)
_____ bilirubin
❖Increased SERUM indicative of liver disease
❖Water-soluble, excreted by kidney
❖All URINE bilirubin is conjugated
Conjugated bilirubin (direct)
oaltered in myriad of diseases especially bone neoplasms
onot specific to liver disease,
omay indicate cholestatic disease
Alkaline phosphatase (high)
Is the Alkaline phosphatase liver function test a specific indicator of liver function?
No
(Transaminases)
–related to glutamic oxalate metabolic pathways
-Produced in kidney and muscles
- AST - Aspartate Aminotransferase (SGOT)–a.k.a. Serum Glutamic-Oxaloacetic Transaminase-
(Transaminases)
–part of pyruvate pathway in cell metabolism
-Produced only in liver
- ALT - Alanine Aminotransferase (SGPT) –a.k.a. Serum Glutamic-Pyruvic Transaminase-
(Transaminases)
needed for protein synthesis
- useful to detect alcohol-induced liver cell injury and chronic alcoholics
- can detect the slightest degree of cholestasis
- sensitive to biliary obstruction, cholangitis, and cholecystitis
- good marker for pancreatic cancer, prostatic carcinoma, and liver cell
-Can show blockage in bile system; alcoholism can affect this too
- Gama-Glutamyl Transferase (GGT)-
AST:ALT ratios more informative
- the _____ the ratio, the more specific an indicator of hepatic disease
lower
_____ (transaminases) more indicative of cholestatic disease and alcoholic liver disease
GGT
If -___ are high:
oIndicates damage to hepatocytes from hepatocellular disease
oNot individually proportionally reflective of severity of liver damage
oUp to 300 UI/L –> non-specific
Transaminases
oSynthesized “exclusively by hepatocytes” oHalf-life: 18-20 days oHypoalbuminemia ❖More indicative of chronic liver disease ❖Not specific to liver disease ✓ Malnutrition ✓ Chronic infection ✓ Gut disease
Albumin (low)
In liver disease, how is prothrombin time effected?
Longer bleeding times than normal; larger number
How are the following function liver tests affected in liver disease? (high or low) Transaminases Albumin Alkaline phosphatase Bilirubin
Transaminases: High
Albumin: Low
Alkaline phosphatase: High
Bilirubin: High
_______:
Bilirubin is not being properly metabolized by liver into bile
-bilirubin ends up in the bloodstream causing yellowish skin
-Gray feces
Jaundicee
All viral hepatitis are ____ virus, except for ______
RNA: Hep B (HBV)
________ –> host immune response to viral antigens rather
than direct cytopathic effect from virus
o Cytotoxic T-cells
o Proinflammatory cytokines
o Natural killer cell response
o Antibody-dependent cellular cytotoxicity
Hepatocellular damage
- Serum hepatitis, blood-borne
* Parenteral, intimate and sexual exposure
Viral Hepatitis
➢ Virus can last for up to 7 days on an infected surface
➢ Incubation period: 90 days average
➢ Chronicity:
o90% for infants
o25-50% in children (1-5)
o<5% in adults
➢ Vaccination
o3 doses (initial, 1 month, 6 months)
oSeroconversion necessary - What does this mean?
➢ Reactivation
➢ Peg- interferon or antivirals such as entecavir and tenofovir
Hepatitis B (Hep B; HBV)
➢ Average prevalence in injection drug user = 53%
➢ Baby boomers should be screened, higher risk of having the virus
➢ 15-25% of untreated patients clear the virus
➢ Has high risk for becoming chronic (75-85%)
o10-20% develop cirrhosis (takes 20-30 years)
oIncreased risk for hepatocellular carcinoma (HCC)
oIncreased risk of death
➢ HCV has higher needlestick transmission rate than HIV
➢ No vaccine
➢ Cure = undetectable HCV RNA levels after 12 weeks of recommended protease
inhibitor therapy
oMavyret (glecaprevir/pibrentasvir)
oEpclusa (sofosbuvir/velpatasvir)
oHarvoni (ledipasvir/sofosbuvir)
Hepatitis C (Hep C; HCV)
➢ Usually coinfection with HBV
➢ More severe than HBV alone
➢ Higher risk of fulminant hepatitis
oMassive hepatocellular destruction
• Hepatitis D (Hep D; HDV)
➢ Infectious hepatitis, fecal-oral transmission
➢ Highly contagious and transmissible
➢ Vaccination available for HAV
Hepatitis A and E
• Most carriers of ___, ____, and _____ are unaware they have hepatitis
• Hepatitis can be contracted by the dentist from an infected patient
• Chronic, active, hepatitis patients may have chronic liver dysfunction
➢ Increased bleeding
➢ Altered drug metabolism
HBV, HCV, HDV
_____ is most likely viral hepatitis to be transmitted occupationally to a dental
health care worker, followed by ______
Hep B; Hep C
Little to no risk exists for transmission of ____ and _____, and non-A-E hepatitis viruses
HAV, HEV
Which hep has a higher needlestick transmission rate than HIV?
HCV
➢ in the 1990s with public attention to higher population incidences of Hep B, dentists
(and other healthcare workers at risk) got the vaccine (3 doses (initial, 1 month, 6
months); then 5 - 10 years later, the HBIg booster was recommended
➢ Most youth get the vaccine today, so there is less public concern;
but standard/universal precautions universal precautions have helped control this
risk
➢ HBV vaccination
How do you treat a pt with active hep?
Defer elective TX If emergency, Consult Med Determine severity and risk Consider referral Isolate well
\_\_\_\_\_\_\_ Oral Manifestations • Bleeding • Mucosal jaundice • Glossitis • Angular cheilosis • Extrahepatic immunologic disorders with chronic HCV ➢ Oral lichen planus ➢ Lymphocytic sialadenitis (Sjögren-like syndrome)
Viral Hepatitis
____ is a liver issue that is hard to diagnose
- Seen more in children than adults while it is more severe
Autoimmune Hepatitis
• May be a cause as well as consequence of liver disease
• Myriad of drugs may cause liver disease (e.g. APAP, clindamycin, etc.)
• Mechanisms
➢ Direct toxicity to hepatocytes
➢ Production of hepatotoxic metabolites
➢ Accumulation of drug due to altered metabolism
Drug-Induced Liver Disease
______ is liver disease that shows decreased hepatic function due to hepatic atrophy
- accumulation of abnormal fats in the liver
- not alcohol based
Nonalcoholic fatty liver diseas
• Alcohol as well as its metabolite are hepatotoxic
• Causes inflammation which compounds the liver damage
• Typically takes 10 years of excessive alcohol intake to develop
➢ Patients first develop fatty liver –reversible
➢ Continual alcohol use and ensuing inflammation can lead to irreversible changes
and necrosis
➢ Eventually with continual use, fibrosis and cirrhosis develop –irreversible -
leading to hepatic failure
Alcoholic liver disease
• Complications of \_\_\_\_\_\_ ➢ Bleeding tendencies –alcohol can impair platelet function ➢ Unpredictable drug metabolism ➢ Potential impaired immune function ➢ Peripheral neuropathies ➢ Dementia and psychosis ➢ Anorexia
Alcoholic Liver disease
• Complications of \_\_\_\_\_\_\_ ➢ Ascites –hepatorenal syndrome ➢ Esophageal varices –GI bleed ➢ Jaundice ➢ Hepatosplenomegaly oEnlarged spleen due to portal hypertension oDecreased platelet function oLeads to thrombocytopenia ➢ Coagulation disorders oDecreased synthesis of clotting factors oImpaired clearance of anticoagulants oDecreased vitamin K absorption (requires biliary excretion) ➢ Hypoalbuminemia ➢ Anemia oIron deficiency oMacrocytosis ➢ Neutropenia ➢ Encephalopathy –neurotoxins not removed from liver
cirrhosis
Severe or mild? liver dysfunction, drug metabolism may conversely be hindered and drug
toxicity is a concern
Severe
mild or severe? dysfunction: Liver enzyme induction may increase metabolism of
prescribed drugs, limiting their effect
Early on/mild
The following signs are signs of _____ leading to _____:
- Spider naevi
- Increased risk of HCC
- Coagulopathy
- Ascites
- Encephalopathy
- Asterixis
- Portal hypertension
Cirrhosis leading to Chronic Liver Disease
Patients with, suspected, active, untreated alcoholic liver disease are or are not
candidates for routine, elective dental treatment?
Are not
_______ is common in those who abuse alcohol
➢ Pts should demonstrate interest and the ability to care for their dentition before
any significant treatment is provided
Oral neglect
AST: ALT ratio ≥__ and ______ GGT are suggestive of alcoholic liver disease
2; elevated
\_\_\_\_\_\_\_ Oral Manifestations • Neglect • Bleeding • Ecchymoses • Petechiae • Glossitis • Angular cheilosis • Alcohol odor • Parotid enlargement (from lymphocytic infiltrate) • Xerostomia
Alcoholic Liver Disease
Alcohol abuse is a strong risk factor
for oral
Squamous cell carcinoma
________ is the number one abused drug in terms of emergency room visits, hospital
admission, family violence, and other social problems
Alcohol Abuse
In Active liver disease, how do we treat?
➢ Treat patient on emergency basis only
➢ Consult physician to determine status
➢ If severe liver disease and requires emergency treatment: consider referral
What is the most important factor mentioned in peri/intra tx of a pt with liver disease?
Control bleeding well
The following are used for \_\_\_\_\_ ❖ Surgicel, Gelfoam ❖ Topical thrombin ❖ Tranexamic acid ❖ Bone wax, ❖ Electrocautery ❖ Silver nitrate sticks ❖ Aminocaproic acid (Amicar) rinse
Bleeding control
Can you prescribe NSAIDs to liver disease pts?
No
can you prescribe acetaminophen to liver disease pts?
Yes; must give proper dose
Generally, Antibiotic prophylaxis prior to procedures is or is not required if no oral infection is
present in liver disease pts?
not required
Patients with ____ LIVER DISEASE may need antibiotic prophylaxis (coverage)
for invasive/surgical procedures due to decreased immune function
SEVERE
Why are local anesthetics problematic for liver disease pt?
Not metabolized in liver
What types of local anesthetics can be used in liver pts due to the fact that it is not as long acting and not as effective but don’t affect liver as much?
Esters
Why are NSAIDs not used in liver pts?
Prolonged bleeding
What opioid can be used in liver disease pts?
Which opioid should NOT be used in liver disease pts?
Hydromorphone
Hydrocodone
Can you use Benzodiazepines in liver disease pts? Why or why not?
No; less metabolism of drug in liver leaving more drug to take effect longer
What sedative can be used in liver disease pts? Why?
Lorazepam; Half of the half life of normal BZD so it sticks around for less time in blood stream to take effect
Why are most antimicrobials contraindicated in liver disease pts?
Not metabolized properly by liver
Why are most antimicrobials not recommended to drink alcohol with?
Severe nausea: Disulfram effect
_________ is a complication of cirrhosis
oBP can be significantly elevated with portal hypertension
oLimit epinephrine (epi)
oDo not use retraction cord with epinephrine
othrombocytopenia (from platelet sequestration in the spleen)
Portal hypertension
