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4th yr- CMS- Medicine > Hepatic impairment > Flashcards

Hepatic impairment Flashcards

1
Q

Why is the uKs health burden to liver disease increasing

A

Due to alcohol abuse

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2
Q

State the major cause of liver disease in the UK

A

Alcohol abuse

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3
Q

Hazardous drinking is how may units in men

A

22-50 units per week

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4
Q

Hazardous drinking is how may units in women

A

15-35 units per week

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5
Q

In whom is alcohol abus most common in

A

Affluent middle class

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6
Q

How many people die annually from alcohol lines illnesses

A

5,500 people

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7
Q

out of 55,000 alcohol related death what causes the highest amount

A

70% of deaths are due to liver cirrhosis

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8
Q

Are men or women more susceptible to alcohol liver disease

A

Women

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9
Q

How many people in England and Wales dependent on alcohol

A

3.8 million

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10
Q

How big is the liver

A

1.5Kg in healthy adults

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11
Q

Where is the liver situated

A

In the upper right abdomen directly inferior to the diaphragm and protected by the rib cage

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12
Q

Describe the vascular properties of the liver

A
  1. 30% of its blood apple is from hepatic artery

2. 70% of its blood from the portal vein

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13
Q

List the main important functions of the liver

A
  1. Processing and Storage of Nutrients Absorbed from the Gut
  2. Bile Synthesis and Excretion
  3. Synthesis of Coagulation Factors and Other Proteins
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14
Q

How are nutrients absorbed by the liver

A

Nutrients absorbed from the intestine travel in the portal vein to the liver where they
are taken up and absorbed by hepatocytes;

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15
Q

What happens to carbohydrates in the liver

A

They are metabolised to glucose in the liver

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16
Q

What happens to glucose in the liver

A

Any glucose that is not used immediately as a source of energy is converted to glycogen

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17
Q

Where is glycogen stored

A

In the liver

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18
Q

Describe glycogen

A

It can be rapidly converted to glucose when extra energy is required

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19
Q

What can we give to patient who are some from hypoglycaemia

A

An intramuscular injection of glucagon

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20
Q

What does glucagon do

A

It converts hepatic glycogen into glucose

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21
Q

When might glucagon not be as effective

A

If a patient hasn’t glycogen stores eg liver cirrhosis,

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22
Q

Name soem vitamins and minerals stored with in the liver

A
  1. Ferritin (iron)

2. Vitamin B12 (80% of body stores).

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23
Q

Why is bile important

A

It is essential for hydrolysis of dietary lipids by pancreatic lipase

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24
Q

Why do we need to hydrolyse dietary lipids

A

So that they can be absorbed through the gut wall into the venous blood

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25
Q

What happens if bile is missing in the small bowel

A
  1. Dietary fats are not absorbed and result in loss pale fatty stools that float and are difficult to flush away
  2. The fat soluble vitamins are not absorbed leading to deficiency states
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26
Q

Name the fat soluble vitamins

A

1, A, D, E and K

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27
Q

Describe bile and what is contain

A

It is a greenish yellow Liquid that includes:

  1. Bile salts
  2. Bilirubin
  3. Cholesterol
  4. Electrolytes
  5. Water
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28
Q

Which cells synthesise bile

A

Hepatocytes

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29
Q

Where is bile secreted into

A
  1. The intrahepatic canaliculi
  2. Then drains into a system of ducts in the liver
  3. Drains into the common hepatic duct
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30
Q

How much Bile does the average adult produce

A

600ml a day

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31
Q

Where can bile temporarily be stored

A

In the gall bladder

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32
Q

How much capacity for bile does the gall bladder have

A

50ml

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33
Q

When does bile enter the gall bladder

A

Ca be stored in the gall bladder before it enters the small bowel via the common Biel duct

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34
Q

why might bile enter the Gall bladder

A

Usually in repose to lipid rich food entering the duodenum

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35
Q

Where is the junction of the bile duct and duodenum found

A

Close to the head of the pancreas

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36
Q

What do hepatocytes do

A

They synthesis:

  1. the vitamin k dependant coagulation factors II, VII, IX and X
  2. Albumin
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37
Q

What is albumin

A

It is major determinant of the blood osmotic pressure

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38
Q

What can reduced albumin levels result in

A

Tissue oedema

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39
Q

Why is albumin important

A

important for binding some circulating drugs.

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40
Q

Name the main cells found in the liver

A

Large population of macrophage lineage cells (Kuppfer cells)

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41
Q

What is the purposes of Kuppfer cells

A

Positioned to destroy bacteria that may have enters the venous blood, primary by crossing the gut wall

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42
Q

The liver is essential to normal vitamin _ metabolism

A

D

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43
Q

What is the importance of vitamin D

A

Promotes the absorption of dietary Ca2+ from the intestine

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44
Q

Which hormone does the liver contribute to the homeostasis of

A

Sex hormones

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45
Q

What can men with chronic liver disease have

A

Abnormal sex hormone metabolism which results in clinical feminization and testicular atrophy

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46
Q

How does the liver play a role drug metabolism

A

Pharmacologically active lipid soluble drugs are converted into pharmacologically inactive hydrophilic metabolites for secretion by the kidneys.

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47
Q

In the UK what is the main cause for liver impairment and failure

A
  1. Alcohol induced cirrhosis
  2. Viral hepatitis
  3. Congenital causes
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48
Q

List some congenital causes of liver failure and impairment

A
  1. Hereditary Haemochromatosis
  2. Wilson’s disease
  3. Alpha 1 antitrypson deficiency
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49
Q

What is hereditary Haemochromatosis

A

A autosomal recessive condition with an incidence of 1 in 200

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50
Q

What does hereditary Haemochromatosis result in

A

Results in inappropriate deposition of iron in tissues and organ from birth which with time may result in impaired organ function

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51
Q

What is Wilson’s disease

A

A rare autosomal recessive disease that is characterised by inappropriate deposition of copper in the liver

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52
Q

What is Alpha 1 antitrypson deficiency

A

A rare autosomal recessive disease where lack of protease Alpha 1 antitrypson results in liver cirrhosis and lung destruction

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53
Q

Where does acquired pathology of liver impairment and failure arise from

A
  1. The bile ducts
  2. The parenchymal cells of the liver
  3. Th blood vessels
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54
Q

What are liver cells called

A

Hepatocytes

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55
Q

Where are the smallest vessels of the biliary tree found

A

Within the liver

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56
Q

Where are the larger terminal vessel and ducts of the biliary tree found

A

Runs outside of the liver and ultimately into the small bowel

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57
Q

If there is pathology of the liver parenchyma which other organ can get damaged

A

Secondary damage of the Biel ducts within the liver can occur

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58
Q

Name the most common disorder of the biliary tree

A

Gallstones

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59
Q

What can gallstones cause

A

May cause obstructive jaundice

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60
Q

What can biliary tree pathology tropical arise due to

A
  1. Lumen obstruction eg gallstones

2. Inflammation and fibrosis of the biliary tree vessel walls

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61
Q

How do gallstones form

A

They are formed from bile salts by mechanism that are poorly understood

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62
Q

Give some symptoms of gallstones

A

Majority are asymptomatic but can be associated with: Biliary colic

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63
Q

What is Biliary colic characterised by

A

Intensely painful spasms as the biliary tree tries to physically move obstructing gallstones

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64
Q

What can happen if bile flow is stopped

A

An obstructive jaundice may develop

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65
Q

How do we manage gallstones

A
  1. Some may spontaneously pass into the small bowel and further intervention is not necessary
  2. May need physical removal the gallstones
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66
Q

How can we surgically intervene to remove a gall bladder

A

Passing an endoscope into the common bile duct from an endoscope passed from the mouth to the duodenum

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67
Q

How can we surgically access for removal of gall baldder

A
  1. Laparoscopic techniques (‘keyhole’ surgery)

2. An open laparotomy (abdominal incision)

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68
Q

What is Primary Biliary Cirrhosis

A

A chronic liver disease characterised by progressive destruction of the small bile ducts within the parenchyma of the liver resulting in duct fibrosis and destruction

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69
Q

What can some people develop if Primary Biliary Cirrhosis goes untreated

A

Can progress to secondary cirrhosis of the liver and associated liver failure
Or secondary Sjögren’s Syndrome;

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70
Q

When do patients usually develop Primary Biliary Cirrhosis

A

Middle age 50

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71
Q

Are men more likely to develop Primary Biliary Cirrhosis or women

A

Women (9:1 ratio)

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72
Q

What is the only effective intervention of more likely to develop Primary Biliary Cirrhosis

A

Liver transplantation but is inly undertaken

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73
Q

What happens in Primary Sclerosing Cholangitis (PSC)?

A

Progressive fibrosis inflammation of bile ducts within and outside the liver parenchyma

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74
Q

What happens if Primary Sclerosing Cholangitis is left untreated

A

Ultimately cirrhosis develops and liver translation may be necessary

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75
Q

Does Primary Sclerosing Cholangitis affect men more or women

A

Typically affects men younger than 50 year olds

76
Q

What is Primary Sclerosing Cholangitis assocated with

A

Ulcerated colitis in 70-80% OF CASES

Cholangiocarcinoma develops in 20-30% of those with PSC.

77
Q

List some acquired disorders of the liver parenchyma

A
  1. Hepatitis
  2. Cirrhosis
  3. Liver cancer
78
Q

What does hepatitis literally mean

A

Inflammation of the liver

79
Q

What can hepatitis be caused by

A
  1. Infections
  2. Drugs and toxins
  3. Autoimmune diseases
  4. Errors of metabolism
  5. Crytogenic
80
Q

Name soem viral infections that can cause hepatitis

A

Hep A, B, C, and E

Herpes virus

81
Q

Name the major global cause of liver impairment

A

Hepatitis C

82
Q

Give examples of herpes viruses that can lead to hepatitis

A
  1. pstein Barr Virus (the cause of ‘glandular fever),
  2. Cytomegalovirus
  3. Varicella Zoster Virus (the cause of chickenpox).
83
Q

Which drugs and toxins can cause hepatitis

A
  1. Alcohol
  2. Prescription paracetamol
  3. Recreational drugs like ecstasy
84
Q

Give examples of autoimmune disease that can lead to hepatitis

A

Autoimmune hepatitis

85
Q

What errors of metabolism can lead to hepatitis

A
  1. Haemochromatosis
  2. Wilsons disease
  3. Alpha 1 antitrypsin deficiency
86
Q

What is cryptogenic

A

When the cause for chronic hepatitis is unknown

87
Q

If hepatitis persists what can it lead to

A

liver cirrhosis

88
Q

What is liver cirrhosis

A

It is a diffuse abnormally of the liver characterised by inappropriate regeneration and fibrosis with formation of structurally abnormal nodules incapable with normal liver function

89
Q

Why might cirrhosis arise

A

As a consequence of:

  1. Hepatocyte damage
  2. Biliary tree pathology within the liver
90
Q

Is a case of liver cirrhosis always found

A

No in 1/3 of case A cause for cirrhosis may not be identified (‘cryptogenic’)

91
Q

Name the 2 types of liver cancer

A

Primary and secondary

92
Q

Give an example of primary liver cancer

A

hepatocellular carcinoma

93
Q

What is secondary liver cancer

A

metastatic from another site

94
Q

How common is hepatocellular carcinoma

A

Uncommon an don accounts for 1 in 200 of all new cancers

95
Q

List several conditions that can predispose to development of hepatocellular carcinoma

A
  1. Chronic hepatitis B or C infection
  2. Aflatoxin from Aspergillus flavus
  3. Parasitic infections such as schistosomiasis
96
Q

Name the main risk factors for liver cancer in the UK

A
  1. Chronic alcohol abuse (most common)
  2. Primary biliary cirrhosis (PBC)
  3. Haemochromatosis
97
Q

How common is secondary cancer

A

In the UK there are approx 70,000 new cases of metastatic liver involvement every year

98
Q

Where does the liver receive blood in health

A
  1. Arterial blood from the heart

2. Venous blood from the gut

99
Q

Give examples,es of acquired disorders fo shelver vasculature

A
  1. Portal hypertension
  2. Gastro-Oesophageal Varices
  3. Splenomegaly
100
Q

What is the portal of the liver

A

Is is the main fissure where the large blood vessels enter and leave the parenchyma of the liver

101
Q

What does portal hypertension refer to

A

Raised venous pressure in liver venous system

102
Q

Give examples of causes of portal hypertension

A
  1. Any state that impaired capillary blood flow through the parenchyma of the liver
  2. Abnormalities of large vessel circulation
103
Q

Abnormalities of which large vessels can lead to portal hypertension

A
  1. Right heart failure

2. Portal vein thrombosis due a hypercoagulable state

104
Q

What can portal hypotension result in

A

Venous connections between the liver and local tissues inappropriately opening and carrying much larger volumes of blood than they do in health

105
Q

What are Varices

A

Abnormal dilation or enlargement of veins

106
Q

Where can Varices develop

A

In the upper stomach and lower oesophageal

107
Q

What can happen to gastro-oesophageal Varices c

A

They may haemorrhage

108
Q

What can the haemorrhage of gastro-oesophageal Varices cause

A
  1. Slowly results in anaemia
  2. haematemesis (vomit blood)
  3. May exsanguinate (bleed to death) unless urgent intervention occurs
109
Q

What is haematemesis

A

Vomiting blood

110
Q

What is exsanguinate

A

bleeding to death

111
Q

How can we intervene to stop exsanguinate

A
  1. Apply pressure to the bleeding varices
  2. Sclerose the bleeding varices by injecting irritant chemicals
  3. Shutnting the blood away from the varices by providing an alternative route fro it to pass
112
Q

What is Splenomegaly

A

When the venous connections between the liver and spleen become engorges with blood and enlarges

113
Q

What is Splenomegaly associated with

A

Hypersplenism

114
Q

What does hypersplenism increase destruction of

A
  1. Erythrocytes via haemolysis with an increased risk of anaemia; and
  2. Platelets: thrombocytopenia with an increased risk of prolonged bleeding.
115
Q

What is thrombocytopenia

A

Reduced platelet count

116
Q

List some clinical features of liver impairment and failure

A
  1. Acute liver failure
  2. Chronic live failure
  3. Jaundice
  4. Prolonged bleeding
  5. Hepatorenal syndrome
  6. Malnutrition, Fluid Overload & Ascites
  7. Nail cahnges
  8. Palmar erythema
  9. Spider naevi
  10. Hepatic encephalopathy
117
Q

What is acute liver disease

A

The abrupt loss of normal hepatic functions

118
Q

What is acute liver disease associated with

A

High morality and mortality

119
Q

List some causes of drug induces necrosis causing acute liver disease

A
  1. Paracetamol overdose
  2. Idiosyncratic drug reactions
  3. Recreational drugs eg ecstasy
120
Q

Name the most common cause of acute liver failure in the UK

A

Paracetamol overdose

121
Q

Give the features of chronic liver failure

122
Q

What is another name for jaundice

123
Q

Name the commonest clinical sign of significant liver impairment

124
Q

What is jaundice caused by

A

Increase in bilirubin levels to around 40 micro moles per litre

125
Q

What is the normal level of bilirubin in the blood

126
Q

Where might we clinically see depositions of bilirubin

A
  1. Sclera (white of the eyes)

2. Skin and mucous membranes

127
Q

What can jaundice be caused by

A
  1. Premature erythrocytes destruction in the blood
  2. Parenchymal liver disease
  3. Obstruction of the biliary tree
128
Q

What can parenchymal liver disease prevent

A

Prevents normal excretion of bilirubin in bile in to the bile ducts which results in raised levels of bilirubin in the blood

129
Q

What can happen if the biliary tree gets obstructed

A

Prevents normal flow of bile in to the small bowel with resultant raised levels of bilirubin in the circulating blood

130
Q

List some clinical signs of impaired coagulation in liver disease

A
  1. Ecchymoses (bruises) of the skin or mucous membranes

2. Prolonged bleeding following trauma

131
Q

How can malnutrition results following chronic liver impairment

A

Multifactorial basis:

  1. Lifestyle factors
  2. Impaired intestinal absorption
  3. Impaired ability of the liver to process the nutrients effectively
  4. Loss of muscle bulk
132
Q

How can fluid overload result following liver disease

A

Reduced hepatic synthesis of plasma proteins leads to excess loss of fluid from the capillaries into the tissues and body cavities as the venous capillary blood lacks the osmotic potential to draw the tissue fluid back into the vessels.

133
Q

Give examples of clinical manifestations of fluid overload

A
  1. Tissue oedema

2. Ascites

134
Q

What are ascites

A

Free fluid in the abdominal cavity

135
Q

How much volume can ascites hold

136
Q

What can ascites result in

A
  1. An increase in total body mass
  2. Impaired respiration due to restriction of diaphragm movement
  3. Gross distension of the abdomen with thin limbs due to the loss of muscle mass
137
Q

What changes can happen to the nails following liver disease

A
  1. Leuconychia

2. Finger clubbing

138
Q

What is Leuconychia

A

White fingernails

139
Q

Why does Leuconychia occur

A

Due to chronic low protein levels

140
Q

What is Palmar erythema

141
Q

What are spider naevi

A

Small dilated capillaries radiating away from a central red arteriole

142
Q

how can hepatic encephalopathy present itself as

A
  1. Drowsiness
  2. A flat affect in mood
  3. Montone speech
  4. Tremor
  5. Poor muscular coordination including difficulty with handwiritn g
143
Q

Give some clinical features of altered steroid hormone metabolism

A
  1. Increased levels of oestrogen
  2. Gynaecomastia (breast enlargement) in men;
  3. Decrease in body hair
  4. Testicular atrophy and
  5. Male impotence
144
Q

What is Gynaecomastia

A

Breast enlargement

145
Q

How can we diagnose and monitor liver impairment and failure

A
  1. Liver function tests (LFTs)
  2. Prothrombin time
  3. Blood tests
  4. Imaging
  5. Liver biopsy
146
Q

When taking an LFT what are we looking fro

A

Levels of:

  1. Bilirubin
  2. Alkaline phosphatase
  3. Alanine transferase
  4. Albumin
147
Q

Where is bilirubin usually excreted from

A

Hepatocytes into the biliary canaliculi within the levels

148
Q

When might bilirubin levels rise

A
  1. Excess production of bile

2. Obstruction of bile flow into the small bowel

149
Q

What is alkaline phosphatase produced by

A

Bile ducts

150
Q

When are levels of alkaline phosphatase raised

A

When there is bile duct obstruction or pathology

151
Q

What is Alanine transferase produced by

A

Hepatocytes

152
Q

When are levels of Alanine transferase raised

A

When there is damage to the liver parenchyma

153
Q

What is albumin produced by

A

Hepatocytes

154
Q

When are levels fo albumin reduced

A

When there is chronic damage to the liver parenchyma

155
Q

What is prothrombin time

A

A measurement of the prothrombin time of a venous blood sample

156
Q

What can prothrombin time give us an indication of

A

Liver function at that point in time

157
Q

How can prothrombin time be expressed

A

International Normalised Ratio (I.N.R)

158
Q

What is prothrombin time influenced by in liver disease

A
  1. Degree of hepatocyte damage resulting in reduced systnetus of vitamin K dependent coagulation factors II, V, VII, IX
  2. Reduced vitamin K absorption fromt eh gut
159
Q

Which coagulation facto has the shortest half life

A

Factor VII

160
Q

What images can we take to assess liver function

A
  1. Ultrasound or MRI scanning

2. Cholangiography

161
Q

What is a crucial functions of the liver

A

Metabolism of drugs

162
Q

Hepatic impairment can have a profound affect on drug…?

A
  1. Pharmacokinetics

2. Pharmacodynamics

163
Q

What is the activity of some drugs influenced by

A

Their degree of protein binding which can be changed in hepatic impairment

164
Q

What is Pharmacodynamics

A

The sensitivity of the target tosses to specific drugs may be other increased or decreased With potentially adverse effects

165
Q

Name some drugs used in oral healthcare what we need have caution in patients with liver impairment or failure

A
  1. Aspirin
  2. NSAIDs
  3. Opioid analgesics
  4. Paracetamol
  5. Erythromycin;
  6. Flucloxacillin;
  7. Metronidazole;
  8. Tetracyclines;
  9. Fluconazole, miconazole and similar drugs
  10. Lignocaine
166
Q

Why do we have to be careful when giving aspirin to patients with liver failure

A

Risk of increased prolonged bleeding

May cause reyes syndrome in children

167
Q

Why do we have to be careful when giving NSAIDs to patients with liver failure

A
  1. Risk of prolonged bleeding;

2. May worsen renal impairment or precipitate renal failure.

168
Q

Why do we have to be careful when giving opioid analgesic to patients with liver failure

A

May cause coma

169
Q

Why do we have to be careful when giving paracetamol to patients with liver failure

A

May cause lever encores and acute failure

170
Q

What is reyes syndrome

A

It is a rare condition in children and adolescents

171
Q

What is reyes syndrome characterised by

A
  1. A portable viral infection

2. A n advise drug reaction aspirin

172
Q

What can happen to a child with reyes syndrome

A 
They rapidly become ill with a multi-system illness that primarily affects the liver and brain with non-specific changes such as:
• Vomiting;
• Drowsiness;
• Irritability;
• Confusion;
• Aggressive or irrational behaviour; 
• Convulsions; and coma.
173
Q

Is reyes syndrome Fatal

A

Mortality is very high 90%

Death occurs within days

174
Q

What should not be prescribed to children with reyes syndrome

175
Q

How can we support liver function in liver failure

A

Renal dialysis awaiting organ transplantation

176
Q

What is the aim of management for liver failure

A
  1. Control symptoms related to liver impairment
  2. Limit any further liver damage
  3. Improve liver function
  4. Undertake organ transplantation at the appropriate time in those close to end stage liver failure
177
Q

Name the only effective intervention for liver failure

A

Liver transplantation

178
Q

Where do most donor livers originate from

A

Patients who are brain stem dead but still have a beating heart
A small number of transplants involve donation from a live donor

179
Q

How probable is graft survival

A

80% at 1 year

180
Q

Why might grafts fail

A

Due to recurrent of the pathology that caused the liver failure
Alcohol abuse

181
Q

What information do we need to from patients with liver disease

A
  1. Underlying causes for liver disease
  2. Known or unknown blood bounce virus infection risk
  3. Problems with prolonged bleeding
  4. Past, current or planned
  5. Does patient have concerns fro oral health
182
Q

How can dentins contribute to the diagnosis fo liver impairment

A
  1. Oral manifestations of decadency states eg low levels of ferritin or vitamin B12
  2. Increased propensity for infections such as oral candidiasis or delayed soft tissue wound healing
  3. Oral manifestations leading to unexplained dryness and secondary Sjogren’s Syndrome with Primary Biliary Cirrhosis.
183
Q

How can dentists contribute to the patients quality of life

A
  1. Maintenance of oral health

2. Recognition and management of orofacial symptoms linked to liver impairment

184
Q

Is a patient with liver failure always going to have the same oral hygiene

A

no circumstances change with time in respect to:

  1. The situation of an individual patient
  2. Understanding and managing of the disease
185
Q

What considerations do you need to take in regards to a liver patients dietary and oral hygiene

A
  1. Impaired liver function may be associated with poor control of blood glucose levels
  2. Soem patients need to snack on carbohydrates through the day to avoid hypoglycaemia
  3. Patients can have a higher number of sugar exposures in a day
  4. Take availably into account before planning love dental procedures
186
Q

What are some of the side effects of liver therapeutic intervention

A

Immunosuppressants or immune modulating drugs, for example following liver transplant can affect oral hygiene

4th yr- CMS- Medicine (14 decks)

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