Hepatobiliary Vascular Disorders and Hepatic Encephalopathy (Rudinsky - Feb 7th - In Class) &Cholestatic Liver Disease (Rudinsky February 9th - In Class)

Question 1

List your treatment options for Congenital PSS:

Answer 1

• Medical management of HE
  
  • Protein- restricted diet
  • Lactulose, antibiotics
  • Correct precipitating events
• Shunt attenuation (Surgery)

Question 2

Congenital PSS
- Extrahepatic PSS
- Hygroscopic casein
- Stainless steel ring
- Fluid absorption
- Shunt occlusion
- Rapid phase (14 d)
- Gradual (up to 60 d)
This is describing …

Answer 2

Ameroid Constrictor

Question 3

List some complications with Ameroid Constrictor:

Answer 3

• Portal Hypertension
• Seizure
• Hemorrhage
• Hypoglycemia
• Treatment failure

Question 4

All surgical shunt corrections should be pre-treated with what?

Answer 4

Antiepileptics (eg Keppra)

Question 5

List Clinical Findings for Microvascular Dysplasia (Portal Vein Hyperplasia):

Answer 5

• Small breed dogs
• Most are asymptomatic
• “PSS lite”
• Older at diagnosis
• Increase SBA; liver biopsy same as congenital PSS

Question 6

(T/F) There are surgical options for Microvascular Dysplasia

Answer 6

False

Question 7

What are the Diagnoses for Hepatic microvascular dysplasia?

Answer 7

• Lab Findings
  
  • Increase SBA
  • Mild Increase ALT
  • No synthetic failure or microcytosis
• Imaging (no shunt)
• Scintigraphy (no shunt) = specific and sensitive
• Liver biopsy (same as PSS)
  (ultrasound = specific not sensitive)

Question 8

EXTRA CARD

Answer 8

Highly Sensitive tests will lead to positive findings for patients with a disease, whereas highly Specific tests will show patients without a finding having no disease.

Question 9

What are the Lab Findings for Microvascular Dysplasia (Portal Vein Hyperplasia)?

Answer 9

• Increase SBA
• Mild Increase ALT
• No synthetic failure or microcytosis

Question 10

(T/F) Microvascular Dysplasia tends to be asymptomatic because the shunt fraction is smaller

Answer 10

True

Question 11

Treatment and Prognosis:
Microvascular Dysplasia (Portal Vein Hyperplasia)
- No treatment required
- Recognition of pre-existing Increase SBA

Answer 11

Asymptomatic

Question 12

Treatment and Prognosis:
Microvascular Dysplasia (Portal Vein Hyperplasia)
- Medical management of HE

Answer 12

Symptomatic

Question 13

(T/F) Hepatic Microvascular Dysplasia (MVD) has a good long term prognosis in most

Answer 13

True

Question 14

• Plasma protein ANTIcoagulant
  - ** Synthesized in the liver **
  - Vitamin K dependent
• Primarily used to differentiate MVD and PSS
  
  • Low protein activity is a characteristic finding in dogs with clinical signs of PSVA
  • Dogs with MVD typically have protein C values > 70%
    
    • > 70% does not differentiate
    • < 70% likely PSS
      This is describing …

Answer 14

Protein C

Question 15

(T/F) High serum bile acids are a sensitive screening test for both PSS and MVD, the finding of high bile acids does not differentiate between these 2 syndromes

Answer 15

True

Question 16

(T/F) Animals with large shunting portosystemic vascular anomalies (PSS) often require surgical correction, whereas microvascular dysplasia (MVD) is not a surgical problem

Answer 16

True

Question 17

What is a sensitive screening test for both PSS and MVD, but the finding does not differentiate between these 2 syndromes?

Answer 17

High serum bile acids

Question 18

List consequences of PSS:

Answer 18

• Hepatic encephalopathy (Big one to worry about)
• Urate urolithiasis
• Hepatic atrophy

Question 19

(T/F) Hepatic Encephalopathy is not reversible

Answer 19

False, is reversible

Question 20

• Pathogenesis unresolved
• Ammonia toxicity is key BUT other factors play a role
  
  • Synergistic toxins
  • Altered neurotransmitters
  • Oxidative stress
  • Inflammatory mediators
• Astrocytes are the target
  This is describing …

Answer 20

Hepatic Encephalopathy

Question 21

Fill in the blanks for Ammonia Metabolism:
- NH3 produced in the colon by bacterial action on dietary protein, protein by-products, and endogenous urea
- NH3 absorbed from colon –> ______(1)______
- Portal blood carries NH3 to ___(2)____
- NH3 –> urea in _____(3)____ (urea cycle)
- NH3 ___(4)___ in peripheral blood

Answer 21

1. portal blood
2. Liver
3. hepatocytes
4. low

Question 22

List causes for Hepatic Encephalopathy:

Answer 22

• PSS
• Severe liver disease
  
  • Massive necrosis
  • Cirrhosis
• Urea cycle enzyme deficiency (uncommon)

Question 23

List treatments for Hepatic Encephalopathy:

Answer 23

• Correct precipitating events
  
  • High protein meal *
  • GI Bleeding *
  • Blood transfusion
  • Constipation
  • Dehydration
  • Azotemia
  • Infection
  • Alkalosis/ decrease K+
• Restrict dietary protein
  - Modify protein: Soy>White>Red>Organ Meat
• Decrease colonic NH3 absorption
• Alter intestinal bacteria

Question 24

Hepatic Encephalopathy:
With what drug therapies do you want to be careful?

Answer 24

Precipitating Events
- Corticosteroids
- NSAIDs
- Tranquilizers
- Anticonvulsants
- Anesthetics
- Diuretics

Question 25

• Synthetic disaccharide
• Not digested or absorbed in the gut
• Metabolized by colonic bacteria to organic acids –> decrease luminal pH (acid)
• Decrease NH3 absorption from the colon
  This is describing …

Answer 25

Lactulose
- Can be given as an enema

Question 26

Hepatic Encephalopathy:
What are the drugs used to alter intestinal bacteria?

Answer 26

• Neomycin (Less systemically absorbed)
• Amoxicillin
• Metronidazole (people go to)

Question 27

(T/F) High serum bile acids are a sensitive screening test of both PSS and MVD, the finding of high bile acids does not differentiate between these 2 syndromes

Answer 27

True