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Acute Care Seminar 1 > Hepatobiliary Disorders > Flashcards

Hepatobiliary Disorders Flashcards

1
Q

Hep A Risk Factor

A

contaminated food or water, fecal-oral

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2
Q

Hep B Risk Factor

A

-residence/travel to Southeast Asia, Africa, blood and body fluid transmission
-Most recover w/out complications
-Antiviral meds: Entecavir, Tenofovir, Interferon

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3
Q

Hep C Risk Factor

A

-IV injection or drug use, blood product before 1990
-Antivirals: Adefovir, entecavir, tenofovir
-Interferon

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4
Q

Hep D Risk Factor

A

only occurs with Hep B, blood or body fluid transmission

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5
Q

Hep E Risk Factor

A

contaminated food or water, fecal-oral, Southeast Asia

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6
Q

Medical Hx to Ask

A

-Dark urine
Pale stools (suggest obstruction)
Arthralgia, myalgia, or rash (? Viral etiology)
Anorexia or weight loss
Abdominal pain
Fever
Itching
Abdominal distension

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7
Q

Portal Vein

A

-carries nutrient-rich blood from the intestine and other parts such as the gallbladder, pancreas and spleen to the liver

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8
Q

Hepatic Vein

A

-carries deoxygenated blood from the liver to the vena cava.

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9
Q

Hepatic Artery

A

supplies oxygen-rich blood to the liver, duodenum, and pancreas.

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10
Q

Bile Duct

A

carries bile from the liver to the small intestine to help with digestion

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11
Q

Liver Physiology

A

-Protein Synthesis
-Detoxification
-Bile Production
-Glucose regulation
-Production of cholesterol
-Vitamin storage
-Iron storage

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12
Q

Liver Disease-PE

A

-Jaundice
JVP (elevation suggests hepatic congestion from right heart failure)
-Lung examination for right pleural effusion
-Shifting dullness and fluid wave (though these are poor predictors for ascites)
-Abdominal tenderness or positive Murphy sign

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13
Q

Hepatocellular

A

-Damage from liver cells
-AST, ALT > than Alk Phos
-Serum bilirubin may be elevated
-Synthetic function maybe abnormal (INR, albumin)

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14
Q

Cholestatic

A

-Decrease in bile flow due to obstruction
-Alk Phos (ALP, Alk Phos) > AST, ALT
-Serum bilirubin maybe elevated
-Maybe abnormal INR and albumin

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15
Q

Alanine Aminotransferase (ALT)

A

-Hepatocellular injury
-“L” is for liver
-also found in skeletal muscle and kidney disorders, more “liver” specific
-Male – 10-55 international unit/L
-Female 7-30 international unit/L

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16
Q

AST - aspartate aminotransferase

A

-Hepatocellular Injury
-also found in the heart, skeletal muscle, kidneys, brain, and red blood cells
-Male – 10-40 international unit/L
-Female – 9-32 international unit/L

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17
Q

AST/ALT Ratio

A

-Most common to have AST < ALT for liver dysfunction
-Remember, ALT is more liver specific

> 2:1 highly suggestive alcoholic disease
Ex: AST 200, ALT 100
-May also be seen in fatty liver (nonalcoholic steatohepatitis)

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18
Q

AST/ALT Ratios in Acute Viral Hepatitis

A

-AST and ALT >25x upper limit of normal (1,000)

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19
Q

Nonalcoholic Steatohepatitis (NASH)

A

-AST and ALT <4 times upper limit of normal (160)
-Do US and liver biopsy
-Many asymptomatic
-Hepatomegaly, fatty liver on biopsy, exclusion of alcohol or other causes

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20
Q

Alcoholic Fatty Liver Disease

A

-AST < 8 times upper limit of normal (320), ALT < 5 times upper limit of normal (200)
-Biopsy, US
-Should improve with cessation of alcohol

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21
Q

AST/ALT Ratios in Ischemic or Drug Induced Hepatitis

A

-AST and ALT > 50 times upper limit of normal (2,000)
-Rhabdomyolysis (polymyositis, seizure)
-Budd-Chiari syndrome
-Sepsis
-Hx of severe Hotn
-Rapid improvement of aminotransferases-dx test

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22
Q

Alkaline Phosphatase

A

-Cholestatic Pattern
-Normal: 20-140 IU/L
-Also found in bone and placenta
-Isolated Alk Phos if AST & ALT normal
-Hyper parathyroidism/Thyroidsim

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23
Q

Glutamyltransferace GGT

A

-most sensitive enzymatic indication of liver disease
-Check if ALP is elevated to distinguish primary liver etiology
Normal 9-48 U/L
-Can be used as screening for alcohol use

24
Q

Isolated Alkaline Phosphatase

A

-Normal GGT with elevated ALP
-Warrants further eval of non hepatic causes (skeletal)
-Refer to endo
-Pagets disease
-Healing Fracture
-Osteomalacia

25
Q

Bilirubin

A

-Total Bilirubin: 0.1-1.2 mg/dL-combo of direct and indirect
-Substance found in bile, digests fats
-Results from breakdown of old red blood cells
-Excreted in bile and urine
-Gives the stool its normal brown color

26
Q

Conjugated Bilirubin

A

-Direct Bilirubin: < 0.3 mg/dL
-Increased due to decreased excretion into the bile ducts
-Leakage of pigment from hepatocytes into serum
—–Isolated conjugated Bilirubin
Dubin-Johnson syndrome
-Rotor syndrome
Present with asymptomatic jaundice, 20s

27
Q

Unconjugated Bilirubin

A

-Indirect: Normal 0.3-1.0 mg/dL
-Increase level is due to overproduction, impaired uptake, or inability to conjugate
-Impaired uptake: med induced
-Bilirubin overproduction-hemolysis (decreased haptoglobin, elevated LDH)

28
Q

Prolonged INR

A

-Med induced
-Hepatocellular function
-Vit K deficiency
->1.1

29
Q

Albumin

A

-Hepatocellular function
-3.4-5.4 g/dL
-Low-chronic process
-Normal-acute process

30
Q

Ammonia

A

-Primary source of ammonia is through GI tract
-Liver converts ammonia to urea, then excreted through stool
-Elevated in non hepatic conditions
Shock, Heavy exercise
Renal disease, After chemo
GI bleed

31
Q

Hematochromatosis (Iron)

A

-Body absorbs too much iron from food
-Clinical cues: arthritis, diabetes, family hx
-Dx tests: iron studies, genetic testing, liver biopsy

32
Q

Wilson’s Disease

A

-Body absorbs and can’t eliminate copper
-Neuro s/s, hemolysis
-Dx tests: Cerulosplasmin, urine copper
-Tx: Chelating agents – bind to copper and released in urine, Zinc acetate

33
Q

Alpha-1 Antitrypsin Deficiency

A

-Genetic condition
-Deficiency in protein leads to damage of hepatocytes and alveolar walls
-Often coincides with early onset emphysema in nonsmokers
-Tx: Supportive therapy of COPD and liver failure

34
Q

Primary Biliary Cirrhosis (PBC): Cholestatic Liver Disease

A

-Chronic and progressive destruction of the small bile duct
-Autoimmune process
-middle aged, fatty deposits skin, nails, palms, elbows, knees, diarrhea, elevated cholesterol, hypothyroidism, osteoporosis
-Dx: Antimitochrondrial antibody, antinuclear antibody, MRCP
-Tx: Ursodiol, Cholestyramine

35
Q

Primary Sclerosing Cholangitis (PSC): Cholestatic Liver Disease

A

-Destruction of the larger biliary tree leading to strictures
-Prone to cholangitis
-Associate w/ ulcerative colitis
-Dx: Cholangiography
-Tx: ERCP with balloon dilation w/ or w/o stenting
Cholestyramine
Ursodiol

36
Q

Large Bile Duct Obstruction: Cholestatic Liver Disease

A

-RF: pregnant, estrogen, DM, fm hx, age, female, inactivity, obesity w/ rapid wt loss
-Jaundice & pain in right shoulder, epigastric to RUQ
-Dx: US, cholangiography

37
Q

Acute Cholecystitis

A

-Inflammation of the gallbladder
-Blockage of the gallbladder by a stone
-+fevers, +pain, + Murphy’s sign

38
Q

Acute Cholecystitis: Choledocholithiasis

A

stone in the common bile duct

39
Q

Acute Cholecystitis: Cholangitis

A

-infection of the bile duct
-Fever, chills, etc.
-Need IV abx
-Gallbladder removal, ERCP
Pancreatitis

40
Q

Acalculous Cholecystitis

A

-Cholecystitis without a stone
-Gallbladder stasis or ischemia
-High morbidity and mortality
-US (no stones, thick gallbladder wall, perforation, gallbladder distention, emphysematous), HIDA scan (look at EF of the liver)
-Abx therapy
-Cholecystectomy versus cholecystostomy tube placement

41
Q

Acetaminophen and Liver disease

A

-Drug induced
-AST >5000 U/L

42
Q

Portal Htn

A

-Chronic disease leads to liver fibrosis
-Progressive fibrosis slows portal blood flow through liver and pressure begins to build within the portal system
-Causes increase protal venous resistance as blood returns to the heart

43
Q

Hepatic Encephalopathy: Tx

A

-Treating underlying cause
-Lactulose 15-30 grams 3-4x/day
-Rifaxamin 550 mg twice per day
-Lactulose 1000 mg retention enema (advanced HE)

44
Q

Esophageal Varices

A

-Screening required for patients with cirrhosis
-Abnormal veins in the lower part of the esophagus
-Esophageal varices usually develop when blood flow to the liver is blocked.

45
Q

Small to Medium Esophageal Variceal Bleed

A

-Start nonselective beta-blocker
-Decrease portal system hypertension
-Propranolol 60 mg daily or
-Nadolol 20 mg daily
-Consider dose at bedtime, keep SBP >90

46
Q

Medium to Large Esophageal Variceal Bleed

A

-Start with nonselective BB
-May need endoscopic variceal ligation
-Propranolol LA 60mg qd
-Nadolol 20mg qd

47
Q

Esophageal Variceal Hemorrhage

A

-Fluid & RBC resuscitation
-Ppx Abx (ceftriaxone 2g q 24 hrs)
-Octreotide 50 mcg IV bolus then 50 mcg/hr
-Protonix 40 mg IV BID
-Reverse coagulopathy
-GI consultation
-If ascites present, obtain paracentesis to evaluate for SBP
-Avoid NSAIDS, ASA, Ginko biloba
-Sengstaken-Blakemore tube, minnesota tube (more current)

48
Q

Octreotide

A

inhibits release of splanchnic vasodilator = reduced splanchnic blood flow and portal venous pressure

49
Q

Correction of Coagulapthy

A

-Depends on coags and location & severity of bleed
-Acute variceal bleed
10 mg vit K IV 1 mg/min
Plt goal >50,000
FFP vs Cryo
Consider checking TEG

50
Q

Transjugular intrahepatic portosystemic shunt (TIPS)

A

Creates a pathway through the liver that connects the portal vein to hepatic vein = reduced portal hypertension

51
Q

Ascites

A

Common complication of liver disease

Natural progression of disease – as ascites develops, increased mortality after development

Often coincides with peripheral edema

52
Q

Ascites Management

A

-Low sodium diet of < 2 grams sodium per da
-Lasix 40 mg daily and/or Spironolactone 100 mg daily
-Monitor sodium and creatinine closely!
-ACE wraps for peripheral edema
-Paracentesis: should be done on all hepatic ascites even if no infection (gram stain, protein count, neutrophil count, culture)

53
Q

Replacement of Albumin: After large vol. paracentesis

A

6-8 grams of 25% albumin per liter of fluid removed

54
Q

Hepatorenal Syndrome

A

-Potential caues of AKI in pts w/ cirrhosis
-Arterial vasodilation within spleen is triggered by portal htn–causes renal vasoconstriction and decreased perfusion to kidneys
-Brought on by acute illness (infection, GIB, encephalopathy)

55
Q

Hepatorenal Syndrome Clinical Presentation

A

-Rise in serum creatinine > 0.3 from baseline
-Proteinuria < 500 mg/24 hours
-Hematuria
-Renal US negative for obstruction
-< 500 mL UOP per day
-Urine sodium < 10 meq/L
-Urine Osmolality > Plasma Osmolality

56
Q

Hepatorenal Syndrome: Management

A

-Ideal is to improve liver function
-Hold diuretics
-Critical Illness in ICU (pressors)
-NonICU; Midodrine, albumin, octreotide
-TIPS candidate?
-Liver transplant
-Need for dialysis

Acute Care Seminar 1 (31 decks)

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