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Kidney + Liver + Endocrine > Liver > Flashcards

Liver Flashcards

1
Q

What is the function of Kupffer cells?

A

Removes bacteria before the blood drains into the vena cava

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2
Q

Where is bile produced?

A

Hepatocytes in the liver

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3
Q

What is the pathway of bile?

A

-Produced
-The canaliculi drains bile into the bile duct
-Bile ducts converge to make the common bile duct
-Cystic duct and the pancreatic duct join the common hepatic duct
-Sphincter of Oddi controls the flow of bile
-Contraction of the sphincter increases biliary pressure

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4
Q

How much CO and blood flow does the liver receive ?

A

30%
1500mL

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5
Q

Which two vessels supplies the liver?

A

Portal Ven

Hepatic artery

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6
Q

Breakdown of the two vessels that supplies the liver?

A

Portal Vein - 75% of Blood and 50% of O2

Hepatic artery - 25% of blood and 50% of O2

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7
Q

What determines portal blood flow?

A

Splanchnic circulation

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8
Q

What is the normal pressure of the portal vein? Sinusoids?

A

Portal 7-10

Sinusoids - 0

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9
Q

What is the diagnostic pressure for portal HTN of the portal vein? Sinusoids?

A

Portal >20

Sinusoids > 5

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10
Q

What is the hepatic arterial buffer response? What mediates this response? What blocks this?

A

If there is a reduction in portal vein flow, it is compensated by increased hepatic artery flow

Mediated through Adenosine

Blocked by severe liver disease

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11
Q

How does GA and neuraxial anesthesia affect hepatic blood flow?

A

Decreases it because of a decreased MAP

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12
Q

What coagulation factors are not produced by hepatocytes?

A

3 - Tissue factor
4- Calcium
vWF - (vasculature)

Still made in the liver but not hepatocytes

8 - antihemophilic factor (liver sinusoidal cells)

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13
Q

Which coagulation factors are dependent on vit K? Which anticoagulants are dependent on endothelial cells?

A

Factors - 2, 7, 9, 10

Anticoagulants - Protein C, Z, S

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14
Q

Which plasma proteins are produced by the liver?

A

Albumin - oncotic pressure and acts as a reservoir for acidic drugs

Alpha 1 - Reservoir for basic drugs

Pseudocholinesterase - metabolizes succ and ester locals

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15
Q

Gluconeogenesis, etc

A
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16
Q

What role does the liver play in amino acid deamination? What happens if they liver can’t?

A

Amino acid deamination allows the body to convert proteins to carbs and fats

this process creates large amount of ammonia. The liver converts ammonia to urea which the kidney eliminates

Failure to clear the ammonia leads to encephalopathy

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17
Q

Where does bili come from? How is it cleared?

A

Recycling of RBCs after 120 days

Eliminated through stool

Spleen
Bound to albumin
Conjugates with glucuronic acid to increase water solubility
Excreted into bile

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18
Q

What are the best tests of hepatic synthetic function? What is the best for acute injury?

A

PT - 12 to 14 seconds
Very sensitive because of short half life

Albumin - 4.0
Not sensitive because of long 21 day half life

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19
Q

Best tests for hepatocellular injury?

A

AST 10-40 units
ALT 10-50 units

Marked elevation of both suggests hepatitis

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20
Q

AST/ALT ratio greater than 2 suggests what?

A

Cirrhosis or alcoholic liver disease

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21
Q

3 tests for biliary duct obstruction? Most specific?

A

***5-Nucleotidase (0-11)

Y Glutamyl transpeptidase (0-30)

Alkaline phosphatase (45-115)

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22
Q

Liver photo

A
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23
Q

Which hepatitis has the highest incidence?

A

A - 50%
B - 35%
C- 15%
D - coinfection with B

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24
Q

How is each hepatitis transmitted?

A

A - oral fecal
B - IV or sex
C- IV
D- IV

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25
Q

How is each hepatitis prevented?

A

A- pooled gamma globulin, Hep A vaccine

B- Hep B immunoglobulin, Hep B vaccine

C- Interferon + Ribavirin

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26
Q

How does Tylenol harm the liver? What is the treatment?

A

Tylenol creates a toxic metabolite called NAPQI but normally glutathione conjugates this

Tylenol consumes all the glutathione which is required for phase 2 reactions

Treatment is oral N-acetylcysteine within 8 hours of overdose

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27
Q

How do halogenated anesthetics harm the liver?

A

Des, Iso, Halothane are metabolized to inorganic fluoride ions and TFA

Halothane is the worst

SEVO does not make TFA

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28
Q

Most common causes of chronic hepatitis ?

A
  1. Alcohol
  2. Hep C
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29
Q

Can patients have surgery with hepatitis?

A

Acute hepatitis - NO

Chronic - yes if stabilized

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30
Q
A
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31
Q

How can hepatic blood flow be maintained?

A

Use iso and avoid halothane

Avoid PEEP

Ensure normocapnia

Liberal use of IV fluids

Regional anesthesia as long as now coag issues

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32
Q

**Which drugs should be avoided with liver failure?

A

Tylenol

Halothane

Amiodarone

Antibiotics: PCN, tetracycline, sulfas

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33
Q

How does alcohol affect MAC?

A

Chronic - increased
Acute - decreased

Alcohol potentiates GABA so an increased affect with benzos

Alcohol inhibits NMDA

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34
Q

Early signs of alcohol withdrawal ? How soon?

A

6-8 hours after BAC returns to normal and peak at 24 hours

Early - Tremors, hallucinations, nightmares

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35
Q

Late signs of alcohol withdrawal ? Treatment?

A

Increased SNS, N/V, agitation, confusion

Treatments - beta blockers, alcohol, alpha 2 agonists

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36
Q

S/sx and treatment for delirium tremens?

A

S/sx - grand mal seizures, tachycardia, hypo/hypertension, combativeness

Treatment - Diazepam or beta blockers

37
Q

Why are alcoholics susceptible to Wernicke-Korsakoff syndrome?

A

They are deficient in B1 (thiamine)

S/sx - loss of neurons in the cerebellum

38
Q

Etiologies of cirrhosis photo

A
39
Q

What is cirrhosis?

A

Healthy liver tissue is replaced with nodules and fibrotic tissue.

40
Q

How does cirrhosis affect liver blood flow? Consequence?

A

Reduces blood flow and increases resistance - portal HTN

Creates collateral vessels

Drugs and toxins remain in the body longer

41
Q

What is a MELD score?

A

Measures 3 factors

Bili, INR, and creatinine

Low risk < 10
Intermediate risk 10-15
High risk > 15

42
Q

What is the child-pugh score?

A

Measures 5 factors

Albumin, PT, bili, ascites, and encephalopathy

Class A, 5-6 points = 10% risk of mortality
Class B, 7-9 points = 30% risk
Class C, 10-15 points = 80%

Class C must be managed medically before surgery

43
Q

How does cirrhosis affect SVR, BP, CO?

A

SVR and BP is decreased

CO is increased

44
Q

How does cirrhosis affect RAA\S?

A

Increased which leads to increased blood volume

45
Q

How does cirrhosis affect peripheral blood flow?

A

Increased which leads to increased SvO2

46
Q

How does cirrhosis affect response to vasopressors?

A

Decreased response

47
Q

How does cirrhosis affect the heart?

A

Diastolic dysfunction

48
Q

How does cirrhosis affect portal HTN? What does portal HTN lead to?

A

Creates portal HTN

Increased to hepatic vascular resistance which increases back pressure to proximal organs

Creates esophageal varices

Splenomegaly which leads to thrombocytopenia

49
Q

How does cirrhosis affect Ascites ?

A

Creates it

Decreased oncotic pressure
Decreased protein binding
Increased Vd
Hypotension

50
Q

How does cirrhosis affect pulmonary?

A

Restrictive disease

Respiratory alkalosis

Hepatopulmonary syndrome

Portopulmonary HTN

51
Q

How does cirrhosis affect encephalopathy?

A

Decreased hepatic clearance which leads to increased ammonia which causes Cerebral edema and INCREASED ICP

Reduce protein, give lactulose and abx

52
Q

How does cirrhosis affect kidneys?

A

Hepatorenal syndrome - Decreased GFR which leads to kidney failure

Renal hypoperfusion - Decreased GFR and Increased RAAS which leads to NA and H2o retention

53
Q

What is a TIPS procedure? What is the biggest risk?

A

Bypasses hepatic circulation and shunts blood from the portal vein to the hepatic vein (outflow vessel)

Reduces back pressure and reduces esophageal varices

Bleeding is a high risk

54
Q

Which hormone stimulates bile release?

A

Cholecystokinin (CCK) stimulates gallbladder contraction

Released due to ingested food

55
Q

Choley photo

A
56
Q

What is cholecystitis? How is it treated?

A

Inflammation of the gallbladder

Cholecystectomy

57
Q

What is cholelithiasis? How is it treated?

A

Gallstones

Cholecystectomy

58
Q

What is choledocholithiasis? How is it treated?

A

Stones in the common bile duct

ERCP

59
Q

Who is at the highest risk for gallstones?

A

3 F’s

Fat
Female
40

60
Q

S/sx of gallstones?

A

Leukocytosis
Fever

RUQ pain - pain is worse during inspiration (Murphy’s sign)

61
Q

What is used to relax the sphincter of ODDI?

A

Glucagon*** - increased risk of PONV

Also

Naloxone
Nitro
Glyco
Atropine

62
Q

Which 3 organs does the celiac artery provide blood flow to?

A

Liver
Spleen
Stomach

63
Q

Which 3 organs does the superior mesenteric artery provide blood flow to?

A

Pancreas
Small intestine
Colon

64
Q

Which organ does the inferior mesenteric artery provide blood to?

A

Colon

65
Q

Which 4 things increase splanchnic vascular resistance?

A

SNS stimulation
Pain
Hypoxia
Propranolol

66
Q

Hepatocytes produce?

A

Thrombopoietin
Alpha-1
Factor 7

67
Q

Which plasma proteins are synthesized in the liver?

A

all of them except immunoglobulins

68
Q

What is

Glycogenesis?
Glycogenolysis?
Gluconeogenesis?

A

Glycogenesis - Glucose is stored as glycogen

Glycogenolysis- Glycogen is cleaved into glucose

Gluconeogenesis- Glucose is created from non carbohydrate sources

69
Q

Normal PT time? What does this measure?

A

12 - 14 seconds?

Synthetic function

70
Q

Normal Albumin? What does this measure?

A

3.5-5 g/dl

Same as potassium

Measures synthetic function

71
Q

Normal AST and ALT? What do these measure?

A

AST- 10 - 40

ALT - 10- 50

Hepatocellular injury

72
Q

Normal Bili? What does this measure?

A

0-11

Hepatic Clearance

73
Q

Normal alkaline phosphatase? What does this measure?

A

45-115 units
Biliary duct obstruction

74
Q

Normal gamma glutamyl transpeptidase? What does this measure?

A

0-30 units

Biliary duct obstruction

75
Q

Normal 5 Nucleosidase? What does this measure?

A

0- 11

Biliary duct obstruction

76
Q

Which hepatitis does not cause cirrhosis or cancer?

A

Hep A

77
Q

Which three drugs are associated with drug induced hepatitis?

A

Halothane
Tylenol
Alcohol

78
Q

What is the typical onset of delirium tremens after a patient stops drinking?

A

2-4 days

79
Q

What are some changes seen in patients with cirrhosis of the liver?

A
  • Right to left shunt
    -Respiratory alkalosis (breathing off acid)
    -Increased CO
    -Decreased GFR and SVR
80
Q

What is the pre anhepatic phase?

A

Surgical incision to cross clamping

Significant blood loss
Risk for aspiration
Will have hemodynamic instability
Prevent hypothermia

81
Q

What is the anhepatic phase?

A

Begins with removal of old liver and ends with implantation of new

Patient will have no liver function
New liver must be in within an hour

*Lower K with hyperventilation, D50, insulin, bicarb, albuterol, CVVHD

82
Q

What is the neohepatic phase?

A

Begins with reperfusion of new liver and ends with biliary anastomosis

-**Highest risk for hyperkalemia
-Avoid high CVP
-Watch temp and electrolytes

  • Post reperfusion syndrome most important consideration. Hypotension more than 30% below baseline for 1 minute
83
Q

What TEE views should be avoided with esophageal varices?

A

All transgastric

84
Q

What special airway consideration for a liver transplant?

A

RSI for risk of aspiration

85
Q

Which two ducts converge at the ampulla of Vater?

A

Pancreatic duct and the common bile duct

86
Q

How does propranolol reduce hepatic blood flow?

A

Constricts the hepatic artery

87
Q

Which zone of the liver is most prone to hypoxic injury?

A

Zone 3 - closest to central vein

88
Q

Most significant risk factors for halothane hepatitis?

A

Female
Fat
Forty

89
Q

Are collateral vessels formed in the inside or outside of the liver in cirrhosis?

A

Outside

Kidney + Liver + Endocrine (6 decks)

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