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Apex > Liver > Flashcards

Liver Flashcards

1
Q

What is a kupffer cell?

A

A type of reticuloendothelial cell responsible for removing bacteria and viruses that enter the liver from the intestine.

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2
Q

What is the largest internal organ?

A

Liver

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3
Q

What is the hepatic acinus?

A

3 zones of hepatic tissue that corresponds with the distance from arterial oxygen (aka portal triad)

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4
Q

What is zone 1 of the hepatic acinus?

A

Most oxygenated

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5
Q

What is zone 2 of the hepatic acinus?

A

Moderately oxygenated

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6
Q

What is zone 3 of to hepatic acinus?

A

Least oxygenated part ~ mostly susceptible to injury

(Also has the highest concentration of CYP 450 enzymes)

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7
Q

What controls the flow of bile released from the common hepatic duct?

A

Sphincter of Oddi

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8
Q

What contacts the sphincter of Oddi?

A

Opioids

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9
Q

What are the 4 fat soluble vitamins that bike helps absorb?

A

DAKE

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10
Q

What does the hepatic artery provide in the liver?

A

25% of the liver blood flow

BUT

50% of the oxygen content

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11
Q

What does the portal vein provide in the liver?

A

75% of the liver blood supply

BUT

50% of the oxygen content

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12
Q

What % of CO does the liver receive?

A

30%

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13
Q

What is a normal pressure in the portal vein?

A

7-10 mmHg

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14
Q

What pressure in the portal vein is diagnostic for portal HTN?

A

> 20-30 mmHg

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15
Q

If there is a reduction in portal vein blood flow, what is the compensatory response?

A

Increasing flow through the hepatic artery

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16
Q

Vitamin K absorption is dependent on what in the gut?

A

Bile in the gut

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17
Q

Where is factor 8 produced?

A

In the liver by SINUSOIDAL cells NOT hepatocytes

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18
Q

What are the ONLY coagulation proteins the liver does not produce?

A

Von Willebrand factor
Factor 3 (tissue factor)
Factor 4 (calcium)

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19
Q

The liver produces all the plasma proteins except what?

A

Immunoglobulins (gamma globulins)

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20
Q

What is albumin a reservoir for?

A

Acidic drugs

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21
Q

What is alpha-1 glycoprotein a reservoir for?

A

Basic drugs!

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22
Q

What does the liver do in a state of hyperglycemia?

A

Glycogenesis > glucose to storage

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23
Q

What does the liver do in a state of hypoglycemia?

A

Glycogenolysis > storage to glucose

Gluconeogenesis > non- carbohydrate to glucose

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24
Q

What happens when the liver is unable to clear ammonia?

A

Hepatic encephalopathy

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25
Q

What causes ammonia in the liver?

A

De-animation of amino acids

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26
Q

What is the process of bilirubin?

A

In the spleen: hemoglobin > heme > unconjugated bilirubin > attaches to albumin

In the liver > conjugates bilirubin with glucuronic acid > increase water solubility > excretion into the bile

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27
Q

What are the liver function tests that determine synthetic function?

A

PT (very sensitive and specific)
Albumin (not sensitive)

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28
Q

What are the liver function tests that determine hepatocellular injury?

A

AST
ALT

(Ranges are 10-40ish)

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29
Q

What is the liver function test that determines hepatic clearance?

A

Bilirubin

(0-11)

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30
Q

What is the liver function test for biliary duct obstruction?

A

Alkaline phosphatase
5’-nucleotidase (most specific to biliary duct obstruction)

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31
Q

What labs does prehepatic injury affect?

A

Bilirubin (unconjugated)

Cause: hematoma reabsorption

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32
Q

What labs does hepatocellular injury affect!

A

Bilirubin (conjugated)
AST
ALT
PT

Causes: cirrhosis, ETOH, drugs, viral infection, sepsis, hypoxemia

(Maybe albumin, but only if chronic)
Maybe alkaline phosphatase

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33
Q

How does post hepatic or cholestatic injury affect liver lab values?

A

Increases alkaline phosphatase
5’nucleotidase
Bilirubin (conjugated)

Causes: biliary tract obstruction/sepsis

***it does also affect AST, ALT, and PT, BUT this is late late disease

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34
Q

what is the most common cause of chronic hepatitis?

A

ETOH

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35
Q

Which two hepatitises (out of the 4) cause cirrhosis and hepatocellular carcinoma?

A

Hep B
Hep C

36
Q

What is the hepatitis with the highest incidence?

A

Hep A

A > B > C > D

37
Q

What are the three main drugs involved in drug-induced hepatitis?

A

Acetaminophen
Halothane
Alcohol

38
Q

What is the max dose of acetaminophen?

39
Q

What is the most common cause of acute liver failure?

A

Acetaminophen overdose

40
Q

What is the treatment for acetaminophen overdose?

A

N-acetylcysteine

41
Q

What is normally conjugated with acetaminophen’s toxic metabolite but is consumed during overdose?

A

Glutathione

42
Q

What does the liver metabolize Des, Iso, and halothane into?

A

Inorganic fluoride ions and trifluoroacetic acid (TFA)

(TFA ~ terrible for Aliver)

43
Q

What is the second most common cause of chronic hepatitis?

44
Q

How does alcohol impair liver function?

A

Impairs fatty metabolism which causes fat accumulation in the liver

45
Q

What inhaled anesthetics should you use for someone with acute hepatitis?

A

Iso or sevo

46
Q

What are some hepatotoxic drugs you should avoid in someone with hepatitis?

A

Acetaminophen
Halothane
Amiodarone
Abx: tetracycline, PCN, Sulfa

47
Q

How does the hepatitis affect Pseudocholinesterase activity?

A

Decreases it > this may increase DOA for Sux and ester local anesthetics

48
Q

How is MAC affected in the acutely drunk? What about chronic?

A

Acute : decreased MAC
Chronic: increased

49
Q

What vitamin are alcoholics deficient in?

A

B1 (thiamine)

50
Q

What is Wernicke-Korsakoff syndrome?

A

Loss of neurons in the cerebellum due to thiamine (B1) deficiency

51
Q

What is the treatment for early alcohol withdrawal syndrome?

A

Alcohol
Beta-blockers
Alpha 2 agonists

52
Q

What is cirrhosis?

A

Characterized by cell death ~ the hepatic tissue is replaced by nodules and fibrotic tissue

***this reduces the number of functional hepatocytes ~ this affects the liver’s ability to perform!

53
Q

How does cirrhosis affect the vascular system of the liver?

A

Nodules/scar tissue block regular blood vessels > reduces the number of functioning vessels > increases resistance > portal hypertension

54
Q

What happens to blood flow when portal hypertension is prominent?

A

Body creates collateral vessels that bypass the liver; call portisystemic shunts

55
Q

A Child-Pugh score of what shows an increased risk of perioperative morbidity?

A

Score of C

56
Q

A MELD score of what shows an increased risk of perioperative morbidity and mortality?

57
Q

What three factors does the MELD score evaluate?

A

Bilirubin
INR
Serum creatinine

(MELD that “BIS” on the head)

58
Q

What 5 factors does the Child-Pugh score evaluate?

A

Albumin
PT
Encephalopathy
Ascites
Bilirubin

Sassy child “I’m here with BAE and PA”

59
Q

How does end stage liver disease affect the cardio system?

A

Portosystemic shunt > vasodilation > reciprocal increase CO

RAAS activation

Increase in shunting > increase SvO2 (not using O2)

Diastolic dysfunction

60
Q

How does end stage liver affect portal HTN?

A

Increase vascular resistance >back pressure in proximal organs > esophageal varies/splenomegaly

61
Q

How does end stage liver disease affect ascites?

A

Decreased oncotic pressure (no proteins) > increased volume distribution > hypovolemia

62
Q

How does end stage liver dx affect the resp system?

A

Ascites > decreased compliance and atelectasis

Hypoxemia > hyperventilation to compensate

Pulmonary vasodilation > shunting

PAP> 25 mmHg

63
Q

How does end stage liver dx affect the CNS?

A

Decreased clearance > increased ammonia > cerebral edema > increased ICP

64
Q

How does end stage liver disease affect autonomic system?

A

Increased SNS and RAAS

65
Q

How does end stage renal disease affect renal?

A

Decrease in GFR > RAAS > Na and H2O retention

Decrease in GFR > renal failure

66
Q

What is the definite treatment in hepatorenal syndrome?

A

Liver transplant

67
Q

How does end stage liver disease affect hematologic systems?

A

Decreased Procoagulants, decreased anticoagulants > bleeding or clot

Thrombopoietin and bone marrow depression > decreased platelet production

68
Q

What is the TIPS procedure?

A

Transjugular intrahepatic portosystemic shunt > bypasses a portion of the hepatic circulation by shunting blood from the portal vein to hepatic vein

*** reduces back pressure on splanchnic organs ~ especially for esophageal varices

69
Q

What is the most significant risk during a TIPS procedure?

A

Hemorrhage

70
Q

What is the main complication in the pre-anhepatic phase?

A

Pulmonary aspiration of gastric contents

71
Q

What is the primary complication during the anhepatic phase?

A

Profound reduction of CO

72
Q

What is the primary complication during the Neohepatic phase?

A

Hyperkalemia

73
Q

what is the most common indication for liver transplant?

A

Hep C baby

74
Q

Can you put a TEE in a patient with esophageal varices?

A

Yes BUT no trans gastric views

75
Q

When does the pre-anheptic stage begin and end?

A

Begins: surgical incision
Ends: cross camping of portal vein, hepatic artery, and IVC

76
Q

When does the anhepatic phase begin and end?

A

Begins: removal of native liver

Ends: implantation of donor liver

77
Q

When does the Neohepatic phase begin and end?

A

Begins: repercussion of donor liver

Ends: biliary anastomosis

78
Q

What are some anesthetic tips for the pre-anhepatic phase?

A

Goals: hemoglobin 7, platelets > 40,000, fibrinogen > 100

CVP low during case and increased to 10 prior to IVC clamp

79
Q

What is the bicaval clamp?

A

Clamps are applied above and below liver during transplantation

80
Q

What is the piggyback technique?

A

Partial obstruction of IVC flow

81
Q

What is VVB?

A

Venovenous bypass ~ this is necessary if a patient does not tolerate piggyback technique

82
Q

What should the warm ischemic time (donor liver is removed till donor liver is reperfused) not exceed?

A

30-60 mins

83
Q

What happens following reperfusion?

A

Serum K will increase

Restoration of blood flow washes out metabolic substances

84
Q

What is the most important consideration during the Neohepatic phase?

A

Post-reperfusion syndrome

85
Q

What is post-reperfusion syndrome?

A

It’s defined as hypotension > 30% below baseline for at least 1 minute during the first 5 mins of reperfusion of the donor liver

Common: 10-60%

86
Q

Which drugs relax the sphincter of Oddi?

A

Glucagon
Glyco
Atropine
Narcan
Nitroglycerin

87
Q

Which sign is associated with cholecystitis?

A

Murphy’s sign!

RUQ ~ Pain is worse on inspo

Apex (47 decks)

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