Hepatobiliary and GI distrubances and Anesthesia

Question 1

The liver receives about ________of the cardiac output via a dual blood supply

Answer 1

The liver receives about 25% of the cardiac output (1,500 mL/min) via a dual blood supply

Question 2

The portal vein provides____of the total liver blood flow and provides ____ of the liver’s oxygen supply.

The hepatic artery provides ___ of the total liver blood flow and provides ____ of the liver’s oxygen supply

Answer 2

The portal vein provides 75% of the total liver blood flow and provides 50% of the liver’s oxygen supply.

The hepatic artery provides 25% of the total liver blood flow and provides 50% of the liver’s oxygen supply

Question 3

True or False: Portal blood flow is autoregulated, and decreased splanchnic vascular resistance reduces portal vein flow.

Answer 3

false

Portal blood flow is not autoregulated, and increased splanchnic vascular resistance reduces portal vein flow

Question 4

When there’s a reduction in portal vein blood flow, the hepatic arterial buffer response compensates by ________ through the hepatic ________.

__________ impairs this response, making the diseased liver even more susceptible to hypoperfusion

Answer 4

When there’s a reduction in portal vein blood flow, the hepatic arterial buffer response compensates by increasing flow through the hepatic artery.

Severe liver disease impairs his response, making the diseased liver even more susceptible to hypoperfusion.

Question 5

__________ and __________ anesthesia reduce _______ and _________.

This can reduce liver blood flow in a dose-dependent fashion.

Answer 5

Both general and neuraxial anesthesia reduces MAP and cardiac output.

This can reduce liver blood flow in a dose-dependent fashion.

Question 6

Liver function

Answer 6

Protein synthesis

Drug biotransformation

Vital role in carbohydrate, protein, and lipid metabolism

Synthesis of fibrinolytics like plasminogen and thrombopoietin, which stimulate platelet production

Regulator of serum glucose. It also clears insulin from the circulation.

Question 7

Which clotting factors the liver produces?

Answer 7

The liver produces all the clotting factors except for factor 3, factor 4, and von Willebrand.

Question 8

Vitamin K-dependent clotting factors include

Answer 8

factors 2, 7, 9, 10, as well as proteins C, S, and Z (anticoagulants)

Question 9

Factor 8 is produced by

Answer 9

Factor 8 is produced by the liver sinusoidal cells and endothelial cells (not by hepatocytes).

Question 10

Patients with liver failure are at risk of

Answer 10

Hypoglycemia

Question 11

Identify the Liver function.

Answer 11

Question 12

The liver produces all the plasma proteins except for _______________

Answer 12

The liver produces all the plasma proteins except for immunoglobulins

Question 13

The most abundant plasma protein

Answer 13

Albumin

Question 14

Which protein serves as a blood reservoir for acidic drugs, but it will also bind with basic drugs?

Answer 14

Albumin

Question 15

Which protein is a blood reservoir for basic drugs?

Answer 15

Alpha-1 acid glycoprotein

Question 16

Reduced pseudocholinesterase production _________ the duration of __________ and possibly increases the duration of _________ local anesthetics.

This is only a problem with _____________.

Answer 16

Reduced pseudocholinesterase production increases the duration of succinylcholine and possibly increases the duration of ester-type local anesthetics.

This is only a problem with severe liver disease.

Question 17

_________ is a byproduct of protein metabolism

Answer 17

Ammonia

Question 18

Failure to clear ammonia leads to

Answer 18

Failure to clear ammonia (hepatic failure or portosystemic shunting) leads to hepatic encephalopathy.

Question 19

________ byproduct of hemoglobin metabolism

Answer 19

Bilirubin

Question 20

Which type of bilirubin is neurotoxic?

Answer 20

Unconjugated bilirubin

Question 21

Phase 1 and Phase 2 of drug metabolism in the liver

Answer 21

Question 22

Liver function test: Synthetic function

Answer 22

PT and Albumin

Question 23

Liver function test: Hepatocellular Injury

Answer 23

ASL and ALT

Question 24

Liver function test: Hepatic Clearance

Answer 24

Bilirubin

Question 25

Liver function test: Biliary duct obstruction

Answer 25

Alkaline phosphatase, Yglutamyl transpeptidase, and 5-nucleotidase

Question 26

___________ is very sensitive for acute hepatic injury because factor 7 has a half-life of only 4 - 6 hours

Answer 26

Prothrombin time is very sensitive for acute hepatic injury because factor 7 has a half-life of only 4 - 6 hours.

Question 27

__________ is not sensitive to acute hepatic injury because it has a half-life of 21 days.

Answer 27

Albumin is not sensitive to acute hepatic injury because it has a half-life of 21 days.

Question 28

Liver Function Test Table

Answer 28

Question 29

What is the most common cause of liver cancer?

Answer 29

Hepatitis

Question 30

What is the most common indication for liver transplantation?

Answer 30

Hepatitis

Question 31

Etiologies of hepatitis include

Answer 31

viruses -herpes simplex CMV Epstein Barr hepatotoxins autoimmune responses

Question 32

Which type of hepatitis is uncommon in the US?

Answer 32

Hepatitis E

Question 33

Hepatitis A virus Route of transmission & Antibody

Answer 33

FECAL-ORAL Anti-HAV

Question 34

Hepatitis B virus Route of Transmission & Antibody

Answer 34

Parenteral Sexual Anti-S Anti- HBc Anti-HBe

Question 35

Hepatitis C virus Route of Transmission & Antibody

Answer 35

Parenteral Anti-HCV

Question 36

Hepatitis D (Delta) virus Route of transmission & Antibody

Answer 36

Parenteral Sexual Anti-HDV

Question 37

Hepatitis E virus Route of Transmission &

Answer 37

Fecal and Oral Anti-HEV

Question 38

What is the most common cause of acute liver failure in the US?

Answer 38

Acetaminophen Overdose

Question 39

What is the most common cause of Drug-Induced hepatitis?

Answer 39

Alcohol It impairs fatty acid metabolism, which causes fat accumulation in the liver. This leads to hepatomegaly.

Question 40

__________ impairs fatty acid metabolism, which causes fat accumulation in the liver. This leads to hepatomegaly.

Answer 40

Alcohol

Question 41

Acetaminophen Overdose treatment

Answer 41

oral N-acetylcysteine within 8 hours of acetaminophen overdose

Question 42

Max dose of Acetaminophen

Answer 42

4g/day

Question 43

Drug-Induced Hepatitis manifestation

Answer 43

Usually associated with a late-onset. It typically presents 2 - 6 weeks after the insult. However, it can be as long as 6 months. It's clinically indistinguishable from viral hepatitis, so laboratory analysis is required

Question 44

Most common cause of chronic hepatitis

Answer 44

Alcoholism

Question 45

The second most common cause of chronic hepatitis

Answer 45

Hepatitis C

Question 46

Diagnosis of Chronic hepatitis include

Answer 46

Increased Liver enzymes and bilirubin + histologic evidence of liver inflammation

Question 47

S/S of chronic hepatitis

Answer 47

jaundice fatigur thrombocytopenia glomerulonephritis neuropathy arthitis myocarditis

Question 48

In Chronic hepatitis the ______is prolonged and ________ is decreased

Answer 48

PT prolonged Albumin Decreased

Question 49

For ________ hepatitis, non-emergent surgery should be postponed until symptoms have resolved and liver function tests return to normal. For _______ hepatitis, the patient may undergo surgery if the condition is stable.

Answer 49

For acute hepatitis, non-emergent surgery should be postponed until symptoms have resolved and liver function tests return to normal.* For chronic hepatitis, the patient may proceed to surgery so long as the condition is stable.

Question 50

What are carcinoid tumors?

Answer 50

Carcinoid tumors consist of slow-growing malignancies composed of enterochromaffin cells and are most found in the GI tract.

Question 51

Where do carcinoid tumors occur?

Answer 51

Most common places to find carcinoid tumors (about 70%) Appendix (45%) Jejunoileum (28%) Rectum (16%) Duodenum (4%)

Question 52

When does carcinoid syndrome develop?

Answer 52

Carcinoid syndrome develops when carcinoid tumors arise outside the drainage field of the hepatic portal venous system or when metastatic disease has replaced so much of the liver as to compromise hepatic synthetic function and systemic symptoms ofserotonin excess occur.

Question 53

Diagnosis of carcinoid tumor includes

Answer 53

Elevated levels (> 30 mg/24 hrs) of 5-hydroxy indole acetic acid (5-HIAA) in urine. Normal levels are from 3-15 mg/24hrs

Question 54

Carcinoid Syndrome is the complex of signs and symptoms caused by the secretion of vasoactive substances such as

Answer 54

Serotonin, kallikrein, and histamine into the systemic circulation from carcinoid tumors.

Question 55

S/S of carcinoid syndrome

Answer 55

Question 56

A carcinoid crisis manifests as

Answer 56

A potentially life-threatening complication. Manifests as intense flushing, diarrhea, abdominal pain, and cardiovascular signs, including tachycardia, hypertension, or hypotension.

Question 57

A Carcinoid crisis may occur.

Answer 57

spontaneously or may be provoked by physical manipulation of the tumor, stress, chemical stimulation or tumor necrosis resulting from chemotherapy hepatic artery ligation or embolization

Question 58

Clinical manifestation of carcinoid crisis

Answer 58

Severe flushing, dramatic changes in BP,arrhythmias, bronchoconstriction, and mental status changes

Question 59

Treatment for carcinoid crisis

Answer 59

Octreotide 150- 200 mcg every 6-8 hours for 24- 48 hours prior to surgery and continued through the procedure

Question 60

Carcinoid syndrome treatment

Answer 60

The most effective treatment for carcinoid tumors is complete surgical excision of the tumor, often with partial bowel resection and mesenteric lymphadenectomy. Somatostatin analogs (Octreotide and Lanreotide )- Suppress luteinizing hormone (LH)responses to gonadotrophin-releasing hormone (GnRH), decrease splanchnic blood flow, and inhibit the release of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide.* Serotonin receptor antagonists: Relieve the diarrhea in most patients.* H1 and H2 receptor blockers: Reduce histamine release and prevent the pruritic flush

Question 61

Hepatic carcinoid tumors receive their blood supply from

Answer 61

the hepatic artery