Hepatic Disease Flashcards
what is the largest internal organ and where is it located
the liver in the right upper quadrant
what is the dual blood supply to the liver and what percent does each contribute and what does each supply
- 20% hepatic artery - oxygenated blood
- 80% portal vein - nutrients
the right hepatic duct and the left hepatic duct come together to form:
the common hepatic duct
what does the common hepatic duct do
- drains bile from the liver
- transports waste from the liver and aids in digestion by releasing bile
what does the common bile duct do
- 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
where does the common bile duct drain into
the GI tract
what do the hepatic veins do
drain venous blood from liver to IVC and on to the right
what does the hepatic artery do
provides oxygen and nutrition to liver tissues
what does the hepatic portal vein do
delivers substances absorbed by the GI tract (stomach, intestine, spleen and pancreas) for metabolic conversion and/or removal in the liver
what are functions of hepatocytes
- synthesizes proteins
- bilirubin is from breakdown of RBCs
- liver conjugates bilirubin by unbinding the protein binding it to glucose; this unconjugated from is in bile
- produces bile for digestion
- produces cholesterol for fat sotrage
- regulates nutrients
- prepares drugs for excretion
- responsible for drug conjugation and metabolism
what proteins do hepatocytes synthesize
- immunoglobulins
- albumin
- coagulation factors
- carrier proteins
- growth hormones
- hormones
bilirubin is transported to liver by being bound to:
albumin (the unconjugated form)
bilirubin levels escalate from:
- blood disorders
- chronic liver diseases
- blockage of bile ducts in liver or gallbladder
- viral hepatitis, EtOH induced hepatitis, drug induced hepatitis, cirrhosis
what blood disorders can cause increased bilirubin levels
- hemolytic anemia
- sickle cell anemia
- inadequate transfusions
what are symptoms of increased bilirbuin
- jaundice
- fatigue
- cutaneous itch
- discolored urine
- discolored feces
what nutrients do hepatocytes regulate
- glucose
- glycogen
- lipids
- amino acids
what drug conjugation and metabolism are hepatocytes responsible for
- bilirubin conjugation
- phase I - cytochrone P450; can produce toxic metabolites
- phase II - conjugation (glucoronidation, sulfation, inactivation by glutatione)
what are the types of liver damage
- hepatocellular - inflammation and injury
- cholestatic
- mixed
- cirrhosis (fibrotic, end-stage) ; acute or chronic
- neoplastic
what are the types of liver disease
- viral hepatitis (A, B, C, D, E, non A-E)
- immune and autoimmune (primary biliary cholangitis, autoimmune hepatitis, GVHD)
- genetic (alpha 1 trysin deficiency, wilson disease)
- NAFLD (obestiy, insulin resistance, lipodystrophy)
- cholestatic syndromes
- systemic disease with liver involvement (sarcoidosis, amyloidosis, TB, glycogen storage disease)
- drug induced liver disease
- hepatocellular carcinoma
- masses, cysts, abscess
what are the signs of liver disease
- jaundice
- ascites
- edema
- GI bleed
- dark urine
- light stool
- mental confusion
- xanthelasma
- spider angiomas
- palmar erythema
- asterixis
- hyperpigmentation
what are the symptoms of liver disease
- appetite loss
- bloating
- nausea
- RUQ pain
- fatigue
- mental confusion
what is a coincident sign and symptom of liver disease
mental confusion
what are xanthelasmas
fatty deposits on the eyes from chronic liver disease history
what conditions can happen with liver disease
- xanthelasmas
- spider angiomas
- asterixis
what is asterixis and what is it also known as
- AKA flapping tremor
- classic sign in hepatic encephalopathy
- jerky movements when hands are extends at wrists
what is asterixis from
indirect effect of liver disease- liver does not synthesize ammonia to ammonium for excretion and it gets into the blood stream
what is hepatic encephalopathy
a syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in patients with severe liver disease
what is the progression of hepatic encephalopathy
- can be a chronic problem in patients with cirrhosis managed medially to varying degrees of success, punctuated with occassional exacerbations
- acute exacerbations are rarely fatal but they are a frequent cause of hospitalizations among patients with cirrhosis
what are the blood tests for liver function
- CBC
- CMP
- lipid panel
- VDRL
-PSA - SARS
- bleeding times
what cells are evaulated in a CBC
- RBCs
- WBCs
- platelets
what does a CBC tell us
- indicator of overall health
- may detect infection, anemia, leukemia, lymphoma, neutropenia
what are other names for CMP
- chemical screen
- SMAC 14 (sequential multiple analysis computer)
what does a CMP test
- 14 blood tests which serve as an initial broad medical screening tool
- general tests
- kidney function assessments
- electrolytes
- protein tests
- liver function assessment
what are the other SMAC variants
8, 12, 16, and 20
the more you analyze in blood tests the more ______
expensive
what proteins can be tested that are involved in liver function
- bilirubin
- alkaline phosphatase (ALP)
- transaminases: aspartate amino transferase (AST), alanine amino transferase (ALT), gama- glutamyl transferase (GGT)
- albumin
- globulin
bilirubin is a product of ____ breakdown
heme
increased total bilirubin means increased:
severity of liver injury
describe unconjugated (indirect) bilirubin and what does it indicate
- 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)
describe conjugated bilirubin (direct) and what it indicates
- increased serum indicative of liver disease
- water soluble, excreted by kidney
- all urine bilirubin is conjugated
describe alkaline phosphatase and what an elevated level of it may indicate
- altered in myriad of diseases especially bone neoplasms
- not specific to liver disease
- may indicate cholestatic disease
what is AST related to
glutamic oxalate metabolic pathways
what is ALT related to
part of pyruvate pathway in cell metabolism
what is gama- glutamyl transferase used for
- needed for protein synthesis
- useful to detect alcohol induced liver cell injury and chronic alcoholics
- can detect the slightest degree of colestasis
- sensitive to biliary obstruction, cholangitis, and cholecystitis
- good marker for pancreatic cancer, prostatic carcinoma, and liver cell carcinoma
what do high levels of transaminases indicate
damage to hepatocytes from hepatocellular disease
- does not reflect severity of liver damage
- up to 300 UI/L -> non specific
what does the AST: ALT ratio tell us
the lower the ratio, the more specific an indicator of hepatic disease
what exclusively synthesizes albumin
hepatocytes
what is the half life of albumin
18-20 days
what does hypoalbuminemia tell us
- more indicative of chronic liver disease
- not specific only to liver disease- it also tells us about malnutrition, chronic infection and gut disease
the liver produces all coagulation factors except
factor 8
PT time measures factors:
I, II, V, VII, and X
what are the vitamin K dependent coagulation factors
II, VII, IX and X
what are the tests in a CMP
- albumin
- alkaline phosphatase
- ALT
- AST
- BUN
- Calcium
- Chloride
- CO2
- creatine
- glucose
- potassium
- sodium
- total bilirubin
- total protein
which viral hepatitis is not an RNA virus? what type of virus is it
Hep B is a enveloped DNA virus
what is hepatocellular damage and what happens in it
- host immune response to viral antigens rather than direct cytopathic effect from virus
- cytotoxic T_cells
- proinflammatory cytokines
- natural killer cell response
- antibody dependent cellular cytotoxicity
viral hepatitis infection ranges from:
asymptomatic/symptomatic to acute/chronic
what are the possible fates of viral hepatitis viruses
- pt may clear the virus or virus may become inactive
- reactivation may occur
chronic hepatitis can lead to:
- cirrhosis
- liver failure
- hepatocellular carcinoma
- risk factor for immunosuppression
what is it called when a hepatitis infection is chronic but asymptomatic
carrier state- low levels of the virus
how long can Hep B last
- up to 7 days on an infected surface
- incubation period is 90 days on average
what is the chronicity for Hep B
- 90% for infants
- 25-50% in children (1-5)
- less than 5% in adults
what is the vaccination for Hep B
3 doses- initial - 1 month and 6 months
can hep b be reactivated
yes
what is the treatment for Hep B
peg interferon or antivirals such as entecavir and tenofovir
how long is the surface antigen present in chronic cases of hepatitis
always
how long is the surface antigen present in acute cases of hepatits
only in the early phases
describe the prevalence of Hep C
- average prevalance in injection drug user is 53%
- baby boomers should be screened- higher risk of having virus
- 15-25% of untreated patients clear the virus
what is the risk of Hep C becoming chronic and what are the risks of chronic hep C
- 75-85%
- 10-20% develop cirrhosis but takes 20-30 years
- increased risk for hepatocellular carcinoma
- increased risk of death
does HIV or HCV have a higher needlestick transmission rate
HCV
is there a vaccine fro HCV
no
what is the a cure for HCV
12 weeks of protease inhibitor therapy
- mavyret
- epclusa
- harvoni
describe Hep D
- usually coninfection with HBV
- more severe than HBV alone
- higher risk of fulminant hepatitis
- massive hepatocellular destruction
describe hep A and Hep E
- infectious hepatitis, fecal-oral transmission
- highly contagious and transmissible
- vaccination available for HAV
- mortality not as high
what can chronic. liver dysfunction cause
- increased bleeding
- altered drug metabolism
what is the most likely viral hepatitis to be transmitted occupationally to a dental healthcare worker
Hep B then Hep C
is there a big risk for transmission of HAV, HEV to dentists
no
reduce oral healthcare worker infection by:
- all patients are considered infectious -> standard precautions
- HBV vaccination
what do you need to determine in viral hepatitis patients
-circumstances of infection - age of onset, source of infection
- status of viral hepatitis- serology, is it treated, viral load
what should you do with patients with active hepatitis
- defer all elective dental treatment
- if emergency treatment: consult with physician, determine severity of disease and dental treatment risk, consider referral, isolation
what should you do with resolved, chronic inactive patients with history of hepatitsi
- consider risk factors
- consult with physician to determine liver status
what should you do if you are stuck with a needle of a hepatitis pateint
- consult with physician
- get the immunoglobulin
what are the oral manifestations of viral hepatitis
- bleeding
- mucosal jaundice
- glossitis
- angular cheilosis
- extrahepatic immunologic disorders with chronic HCV such as lichen planus and lymphocytic sialadenitis
what is the mechanism of drug induced liver disease
- direct toxicity to hepatocytes
- production of hepatotoxic metabolites
- accumulation of drug to altered metabolism
alcohol and its metabolite are ______
hepatotoxic
what does alcohol do to the liver
causes inflammation
what is the progression of alcoholic liver disease
- 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
wwhat are the complications of alcoholic liver disease
- bleeding tendencies- alcohol can impair platelet function
- unpredictabe drug metabolism
- potential impaired immune function
- peripheral neuropathies
- dementia and psychossis
- anorexia
what are the complications of cirrhosis
- ascites - hepatorenal syndrome
- esophageal varices
- jaundice
- hepatosplenomegaly
- coagulation disorders
- hypoalbuminemia
- anemia
- neutropenia
- encephalopathy
what is hepatosplenomegaly
- enlarged spleen due to portal hypertension
- decreased platelet function
- leads to thrombocytopenia
what happens in coagulation disorders
- decreased synthesis of clotting factors
- impaired clearance of anticoagulants
- decreased vitamin K absorption
what are the types of anemia caused by alcoholic liver disease
- iron deficiency
- macrocytosis
what causes encephalopahty
neurotoxins not removed from the liver
how can you identify alcoholic patients
- history
- clinical exam
- detection of odor on breath
- suspicious behavior
- information from family/friend
describe metabolism during early on/mild liver dysfunction in alcoholic liver disease
liver enzyme induction may increase metabolism of prescribed drugs limiting their effect
describe metabolism in severe liver dysfuction
drug metabolism may be hindered and drug toxicity is a concern
what are the main feautres of cirrhosis
- encephalopathy: confusion, coma, asterixis
- spider nevi
- coagulopathy
- ascites
- increased risk of hepatocellular carcinoma
are patients with suspected, active, untreated alcoholic liver disease candidates for routine elective dnetal tx
no
oral neglect is common in those who _____
abuse alcohol
what levels suggest alcoholic liver disease
AST: ALT ratio less than 2 and elevated GGT
what are the values of total protein, globulin, A/G ratio, alkaline phosphatase, ALT and AST in hepatitis
- total protein: normal
- albumin: normal
- globulin: normal
- A/G ratio: greater than 1
- alkaline phosphatase: elevated
- ALT: increased
- AST: increased
ALT is always _____ than AST
greater
what are the values of total protein, globulin, A/G ratio, alkaline phosphatase, ALT and AST in cirrhosis
- total protein: decreased
- albumin: decreased
- globulin: increased
- A/G ratio: less than 1
- alkaline phosphatase: elevated
- ALT: increased
- AST: increased
what are the oral manifestations of alcoholic liver disease
- neglect
- bleeding
- ecchymoses
- petechiae
- glossitis
- angular cheilosis
- alcohol odor
- parotid enlargement
- xerostomia
wha tis the number one abused drug in terms of ER visits, hospital admission , family violence and other social problems
alcohol
alcohol abuse is a strong risk factor for what cancer
oral squamous cell carcinoma
what does the breath of an alcoholic smell like
sweet and musty
what tests should be done to evaluate the fitness of the patient for dental treatment in liver disease
- CBC with differential
- liver function test
- bleeding studies
what liver function tests should be included in a liver disease patient
- AST
- ALT
- GGT
- albumin
- alkaline phosphatase
- bilirubin
what bleeding studied should be ordered in a liver disease pt
- PT
- bleeding time
what should you do with a paitent with acute liver disease
- treat on emergency basis only
- consult with phsycician
- if severe liver disease and requires emergency tx refer to center
what history should you gather in a pt with liver disease
- age of onset
- consult wtih physician to determine status and medication
- compensated disaeaase or decompensated disease
- assess other end organ damage such as: gallbladder, renal, CV, hematologic disease
what are the preoperative strategies to deal with bleeding complications in a pt with liver disease
- consult with physician concerning liver disease status
- review meds to assess possible medication related bleeding risk
- request relevant labs and check results to confirm if it is safe to proceed
what are the peri/intra operative strategies to deal with bleeding complications in a pt with liver disease
- perform extractions as atraumatically as possible
- if perfroming a SRP do one tooth at a time rather than an entire quad
- have local hemostatic agents available
- place sutures in all extraction sites
what are the local hemostatic agents
- surgicel, gelfoam
- topical thromin
- tranexamic acid
- bone wac
- electrocautery
- silver nitrate sticks
- aminocaproic acid rince
what are the post operative strategies to deal with bleeding complications in a pt with liver disease
- pt sit in chair for 20 minutes after procedure and assess that local hemostasis is good
- explain verbally and have written post op instructions available for the pt
- do not prescribe NSAIDS
- can give up to 2 mg of acetominophen daily
- supply pt with gauze
- reinforce the need to maintain clot in place- no straws, no spitting, avoid taking and maintain soft diet for 2-3 days
- call if bleeding persists
when is antibiotic prophylaxis required
when oral infection is present
should you give AB prophylaxis to severe liver disease patient for surgical procedures and why or why not
yes due to decreased immune function
what drugs should you not give and which can you give
- minimize drugs metabolized by the liver
- local anesthetic
- analgesics
- sedatives
- antimicrobials
- avoid benxodiazepines
- lorazepam may be used
- nitrous may be used
- esters okay!!!
what can high doses of acetominophen lead to
toxicity and liver failure
if opioids are necessary what is the preferred choice and why
hydromorphone because of glucoronidation
why should you avoid hydrocodone and oxycodone
unpredictable metabolism
what antimicrobials should you avoid in pt with liver disease
- metronidazole
- tetracycline
- doxycycline
- antifunglas
- clindamycin
no alcohol with antibiotics - 2nd and 3rd generation cephalosporins- disulfiram effect, can cause extreme vomitting
what are the cautions with portal hypertension in liver disease pt
- BP can be elevated with portal HTN
- limit EPI
- do not use retraction cord with epi
- thrombocytopenia
what is the weight risk: benefit ratio in severe liver disease patients
impairment of drug metabolism : immune impairment
