Liver Flashcards
test 3
The liver is divided into ____ segments
8
What are the functions of the liver?
-synthesize glucose via gluconeogenesis
-stores glucose as glycogen
-synthesize cholesterol and proteins into hormones and vitamins
-metabolize, fat, protein, carbs to generate energy
-metabolizes drugs via CYP – 450 and other enzyme pathways
-detoxifies blood
-involved in acute phase of immune support
-processes hgb and stores iron
-synthesize coagulation factors (except F III, IV, VIII, vWF)
-aids in volume control as blood reservoir
T/F: almost every organ is impacted by the liver & and liver dysfunction can lead to MOSF
T
Which side of the liver is bigger?
R
What separates the R & L lobes of the liver?
Falciform Ligament
T/F: The liver has 4 blood supplies and each segment shares a blood supply and a bile drainage
F
Each segment has its own blood supply & bile drainage (8)
What supplies blood to the liver?
Portal vein
hepatic artery
_____ hepatic veins empty into _____. What are they?
3
IVC
R; middle; L
How does bile drain?
Hepatic ducts –> gall bladder –> common bile duct –> ampulla of vater –> duodenum
The ______ connects the Pancreas & gallbladder. This leads to the ________
Ampulla of Vater
Duodenum
What happens in the duodenum?
Bile flows here and breaks down fatty acids for digestion
The liver receives ___% of CO which is about _____ L/min
25%
1.25 - 1.5 L/min
T/F: the liver has the highest proportionate of CO of all organs
T
The Portal vein rises from what veins?
Splanchnic vein
Superior mesenteric vein
Portal vein blood is partially __________. Why?
Deoxygenated
Has to perfuse G.I. organs, pancreas, spleen first
The hepatic artery branches off of what?
The aorta
The portal vein provides ___% of HBF and the hepatic artery provide provides ___% of HBF. How much O2 delivery does each vein provide?
75%
25%
Both provide 50% equally
Hepatic artery blood flow is _____ related to portal vein blood flow. What is the MOA behind this?
Inversely
if one decreases the other increases
Autoregulation: hepatic artery will dilate in response to low portal venous flow
What is portal Venus pressure a reflection of?
Splanchnic arterial tone
intraheptatic pressure
What happens if there is increased portal Venus pressure? What causes this?
Blood back up into systemic circulation –> esophageal/gastric varices
causes: Cirrhosis or sclerosis of liver
What is the hepatic venous pressure gradient values used to determine portal hypertension?
HVPG 1-5 mmHg: normal
> 10: clinically significant portal, hypertension
> 12: Variceal rupture
(Emergency; need banding; can result in death)
T/F: liver symptoms often show very early
F
Often asymptomatic until late stage liver disease
We heavily rely on ______ for degree of suspicion with liver disease
Risk factors
what are risk factors for liver disease?
-Family hx
-heavy ETOH
-high risk lifestyle
-DM
-obesity
-illicit drug use
-multiple sex partner
-DIY tattoos
-blood transfusions
What are the presentations on a physical exam for liver disease?
-pruitis (dt increased bilirubin)
-jaundice
-ascites
-asterixis (flapping tremor)
-Hepatomegaly
-Splenomegaly
-Spider nevi (little vessels)
What are our best lab indicators for liver dysfunction? Which is most liver specific?
AST - Aspartate aminotransferase
ALT - Alanine aminotransferase <– more liver specific
What labs do you need for liver function?
-BMP
-CBC
-PT/INR
-AST
-ALT
-Bilirubin
-alkaline phosphatase
-GGT - y-glutamyl-transferase
What type of imaging can you use to Dx liver disease?
-US
-Doppler (Portal blood flow)
-CT
-MRI
What labs are affected in hepatocellular injury? Differentiate between ALF/ ALD/ NAFLD
-increased AST/ALT
Acute liver failure (ALF): elevated 25x
Alcoholic liver disease (ALD): AST: ALT ratio at least 2:1 (both elevated)
Non-alcoholic fatty liver disease (NAFLD): 1:1 with both elevated
What labs are affected in reduced synthetic function?
Decreased albumin
Increased PT/INR
What labs are affected in cholestasis?
Increased Alk phosphatase, GGT, bilirubin
What is Cholestasis?
Sluggish/lack of bile flow
______ is the ONLY pathology that has elevated unconjugated bilirubin
Bilirubin overload dt hemolysis
ALL OTHERS ARE CONJUGATED
Describe Cholelithiasis: Risk factors; S/S; Tx
Gallstones: hinders flow of bile to small intestines –> can’t break down fatty acids
Risk factors: obesity; increased cholesterol; DM; pregnancy; female; family hx
S/S: RUQ pain referred to shoulders; N/V; indigestion; fever
Tx: IVF, Abx, pain management
lap chole (last resort)
____% of Cholelithiasis is asymptomatic
80%
______ releases bile during meals & ______ release his bile continuously into the duodenum
Gallbladder
Common bile duct
The _______ technique is the most common now for Lap Chole
Laproscopic
Describe Choledocolithiasis: Risk factors; S/S; Tx
Stones constructing common bile duct –> causing bile to reflux (biliary colic)
Risk factors: obesity; increased cholesterol; DM; pregnancy; female; family hx
S/S: N/V; cramping; RUQ pain; fever; rigors; jaundice
Tx: endoscopic removal of stone via ERCP (endoscopic retrograde Cholangiopancreatography)
Describe the procedure of ERCP
To remove a stone obstructing CBD (Choledocolithiasis)
Guide wire through Sphincter of odds –> ampulla of vater –> to get stone from pancreatic duct/CBD
Pt position: prone w/ left tilt
ETT taped to L
Surgeon puts tube down R
______ helps prevent Oddi spasm. What is the dose for this?
Glucagon
1mg
What is bilirubin? Unconjugated? Conjugated?
End product of heme-breakdown
Unconjugated (indirect): Protein bound to albumin –> transported to liver –> conjugated into water soluble, conjugated (direct) form –> excreted into bile
What is the difference between unconjugated hyperbilirubinemia and conjugated hyperbilirubinemia?
unconjugated: imbalance of bilirubin synthesis & conjugation
conjugated: obstruction, causing reflux of conjugated bilirubin into circulation
What are the five types of hepatitis? Which types are more chronic?
A, B, C, D, E
B & C
The decline in hepatitis is due to what?
Vaccines and new treatments
_____ is the most common viral hepatitis requiring liver transplant
HCV
Treatment of HCV is 75% based on genotype _____. What is the treatment for this?
Type 1
Tx: Sofosbuvir/Velpatasvir (antiviral)
12 week course provides 98-99% clearance
Common symptoms for hepatitis include:
-fatigue
-jaundice
-N/V
-loss of appetite
-bleeding/bruising
-dark urine
Which type of hepatitis can be spread by percutaneous and sexual contact?
B & C
in HCV, ____% of people develop chronic liver disease
75%
In Hep B, ___% of adults and ____% of children developed chronic liver disease
1-5%
80-90%
Which types of hepatitis can be spread through fecal and water?
A & E
What is the most common cause of cirrhosis and liver transplant?
Alcoholic liver disease (ALD)
With ALD, if your platelets drop below _________ it requires a blood transfusion
50,000
What are symptoms of ALD?
-malnutrition
-muscle wasting
-parotid gland hypertrophy
-jaundice
-thrombocytopenia
-ascities
-hepatosplenomegaly
-pedal edema
-withdrawl
With ALD, withdraw normally occurs ______ after stopping drinking
24 - 72 hrs
What are the lab values with ALD?
-Increase MCV (mean corpuscular volume)
-increase liver enzymes
-increase GGT
-increase Bilirubin
-increase blood ethanol
describe non-alcoholic fatty liver disease (NAFLD): Rx; Dx; Tx
Hepatocytes contain >5% fat
Risk factors: obesity; insulin; DM2; metabolic syndrome
Dx: imaging; liver biopsy (gold standard)
Tx: diet and exercise
Liver transplant for advancement to cirrhosis/fibrosis
_______ have NAFLD regardless of weight
1/4 or 25%
What are the stages of NAFLD?
NAFL –> Non-alcoholic Steatohepatitis (NASH) –> Liver Fibrosis –> Cirrhosis
What are the stages of AFLD?
AFLD –> Alcoholic hepatitis –> cirrhosis
Describe Autoimmune Hepatitis: S/S; Dx; Tx
Not fully understood
S/S: a asymptomatic, chronic, or acute
Dx: (+) autoantibodies;
hypergammaglbulinemia
AST/ALT 10-20x normal
Tx: steroids
Azathioprine (immunosuppressant)
Liver transplant
Autoimmune Hepatitis primarily affects _______
women
T/F: With autoimmune hepatits 60-80% achieve remission but relapse is common
T
May need transplant
Most common drug induced liver injury is caused by ________
Acetaminophen OD
What are the 3 specific genetic disorders regarding metabolism w/ the liver? Describe onset and mortality
-Wilson’s disease
-alpha-1 Antitrypsin deficiency
-hemochromatosis
Onset: varies from birth to teen
Most severe forms are in neonatal period
High mortality
Liver genetic disorders regarding metabolism occur is _______ births
1/2500
Wilsons Disease is also called _________ and is an _________ genetic disease. What is it characterized by?
Hepatolenticular degeneration
Autosomal recessive
Impaired copper metabolism
Describe Wilsons Disease: S/S; Dx; Tx
Impaired copper metabolism –> copper build up –> oxidative stress to liver, basal ganglia, cornea
S/S: asymptomatic
Sudden onset liver failure
Neurologic manifestations
Psychiatric manifestations
Dx: lab test (elevated serum ceruliplasmin, aminotransferases, urine copper)
Liver biopsy
Tx: Copper-chelation therapy
PO Zinc (binds to copper in GI tract)
Describe Alpha-1 Antitrypsin deficiency: Dx; Tx
Genetic disorder resulting in defective alpha-1 Antitrypsin protein
Dx: alpha-1 Antitrypsin phenotyping
Tx: pooled alpha-1 Antitrypsin effective for pulm symptoms
Liver transplant is the only cure
alpha-1 Antitrypsin deficiency protects the liver/lungs from __________. What does this do?
Neutrophil elastase
enzyme that disrupts lung/liver tissue
alpha-1 Antitrypsin deficiency incidence is _______
1:16,000 to 1:35,000
Likely under diagnosed
What is the #1 genetic cause of liver transplant in children?
alpha-1 Antitrypsin deficiency
T/F: Liver transplant is the only cure in alpha-1 Antitrypsin deficiency
T
Describe Hemochromatosis: S/S; Dx; Tx
Excessive intestinal absorption of iron –> iron accumulates in organs –> damages tissues
-genetic or caused by excessive blood/iron transfusion
S/S: cirrhosis
-HF
-DM
-adrenal insufficiency
-polyarthropathy
Dx: genetic mutation testing
Echo
MRI
Liver biopsy
Tx: weekly phlebotomy
Iron-chelatin drugs
Liver transplant
Describe Primary Sclerosing Cholangitis (PSC): S/S; Dx; Tx
Autoimmune, chronic inflammation of larger bile ducts of biliary tree
-intra/extrahepatic
-Fibrosis of biliary tree –> stictures –> cirrhosis –> ESLD
S/S: fatigue
-itching
-deficiency of fat soluble vitamins (A., D, E, K)
-cirrhosis
Dx: MRCP
-ERCP
-liver biopsy
Tx: no drug treatment are effective
liver transplant, only long-term Tx
REOCCURENCE IS COMMON AFTER TRANSPLANT
What is a hallmark symptom of Primary Sclerosing Cholangitis?
strictures or beads on string appearance on biliary tree
Primary Sclerosing Cholangitis is more common ins ______ and has an onset of _____
Males
about 40 yo
T/F: With Primary Sclerosing Cholangitis, Tranplant is final tx
F
Reoccurence is common even after transplant
This is a lifeling problem.
Describe Primary Biliary Cholangitis (PSC): causes; S/S; Dx; Tx
Auto immune destruction of bile ducts with periportal inflammation & cholestasis
-can lead to liver scarring, fibrosis, cirrhosis
Causes: exposure to environmental toxins and genetically susceptible individuals
S/S: jaundice
-fatigue
-itching
Dx: increase Alk Phos, GGT
(+) antimitochondrial antibodies
Imaging (CT, MRI, MRCP, US)
Liver biopsy
Tx: no cure
Exogenous bile acids can slow production
Primary Biliary Cholangitis was previously known as _______
biliary cirrhosis
Primary Biliary Cholangitis is more common in _____ an occurs in _____ ages
Women
Middle ages
What is the difference between Primary Sclerosing Cholangitis & Primary Biliary Cholangitis?
Primary Sclerosing Cholangitis: Stictures: bead like structures on biliary tree
intra/extrahepatic
Primary Biliary Cholangitis: small ducts
intrahepatic only
Describe Acute liver failure: causes; S/S; Dx; Tx
Life-threatening severe liver injury
Occurs within days to 6 month after insult
-massive heptacyte necrosis –> cellular swelling –> membrane disruption in liver
causes: 50% drug induced (most acetaminophen)
-Viral hepatitis
-auto immune
-hypoxia
-ALF of pregnancy
-HELLP
S/S: jaundice
-nausea
-RUQ pain
-cerebral edema
-encephalopathy
-multiorgan failure
-death
Tx: treat cause
Supportive care
Liver transplant
What is the final stage of liver disease? What is it exactly?
Cirrhosis
Normal liver parenchyma replaced with/ scar tissue
Describe cirrhosis: causes; S/S; Dx; Tx
Final stage of liver disease
Liver covered with scar tissue
Causes: ALD
NAFL
HCV
HBV
S/S: jaundice
-ascities
-varices
-coagulopathy
-encephalopathy
-lack of body hair
-muscle wasting
-red palms
-widened blood vessels
-spider angioma
Dx: elevated AST, ALT, Bilirubin, Alk phos, PT/INR
Thrombocytopenia
Tx: transplant is only cure
What are cirrhosis complications? (8)
Bacterial Peritonitis
Hepatic Encephalopathy
Ascities
Varices
Hepatorenal syndrome
Hepatopulmonary syndrome
Portal HTN
Portopulmonary HTN
what is the TIPS procedure?
Transjugular intrahepatic portosystemic shunt: reduces portal HTN & ascities
Stent/graft placed between hepatic vein & portal vein –> shunts portal flow to systemic circulation
Describe Bacterial Peritonitis
Complication of cirrhosis
infection in ascities and fluid
Requires abx
Describe Hepatic Encephalopathy
Complication of cirrhosis
Dt nitrogen buildup –> Neuropsych symptoms
Tx: lactulose; rifaximin
Describe Ascities
most common complication of cirrhosis
Portal HTN –> increase blood volume –> peritoneal fluid accumulation
Management: decrease salt intake; replace albumin
TIPS procedure
Describe Varices
Complication of cirrhosis
In 50% of cirrhosis pts
Hemorrhage is most lethal complication
BB reduce risk
Tx: prophylactic endoscopic variceal banding & ligation
Balloon tamponade
Describe Hepatorenal syndrome
Complication of cirrhosis
excessive production of endogenous, vasodilators (NO, PG) –> decrease RBF
Tx: Midodrine; Octreotide; Albumin
Describe Hepatopulmonary syndrome
Complication of cirrhosis
Triad of chronic liver disease, hypoxemia, intrapulmonary vascular dilation
S/S: Platypnea: hypoxemia when upright dt R to L intrapulmonary shunt
Describe Portal HTN
Complication of cirrhosis
HVPG >5
Describe Portopulmonary HTN
Pulmonary HTN accompanied by portal HTN
Systemic vasodilation –> pulmonary vasoconstriction
Tx: phosphodiesterase inhibitors
-NO
-prostacyclin analogs
-endothelin receptor antagonist
—–Drugs only manage symptoms—–
Transplant is only cure
What are the two scoring assistance to determine severity and prognosis of liver disease? What does the score indicate?
Child-Turcotte-Pugh (CTP)
Model for in stage liver disease (MELD)
Increase score = increase mortality
Liver disease algorithm:
No cirrhosis? –> OR
MELD < 10 or Child class A –> OR
MELD 10-15 or Child class B –> No portal HTN? –> OR with careful peri/postop monitoring
Yes portal HTN –> Consider TIPS; discuss how to optimize before OR; cancel if elective until TIPS
MELD > 16 or Child class C –> alt to Sx & workup for transplant unless emergent
Alcoholism ______ MAC of volatile anesthetics
Increases
Succs & Cisatracurium are metabolized in the ________. Are they good for liver disease pts?
Plasma
Yes. not metabolized by liver
What types of fluids are preferred with liver disease in resuscitation?
Natural colloids
Ex. albumin.
Not crystalloids
Not synthetic colloids
What does liver disease put you more at risk for?
Aspiration
Hypotension
Hypoxemia
T/F: plasma cholinesterase maybe decrease in severe liver disease.
T
this can effect drugs that are metabolized in the plasma
What are contras to TIPS procedure?
HF
Tricuspid regurg
Severe pulm HTN
What are indications to TIPS procedure?
Refractory Varices hemorrhage
Refractory ascities
Up to _____% removal is tolerated in pt for a partial hepatectomy w/ normal liver function
75%
What are anesthesia considerations we should have with a partial hepatectomy?
-invasive monitoring
-available blood products
-adequate vascular access for blood/pressors
With a partial hepatectomy, the surgeon may clamp ______ or _______ to control blood loss
IVC
Hepatic artery
With a partial hepatectomy, standard practice is to maintain _____ CVP by _______. What does this do?
Low
Fluid restriction
Helps to reduce blood loss
partial hepatectomy Pts require a postop ______ because this is a very painful procedure
PCA
What are the most common indications for liver transplant?
ALD > fatty liver > HCC (cancer)
In this order
what is the definitive treatment for ESLD?
Liver transplant
For a liver transplant with a living donor, how are the surgeries timed?
Both surgeries have to be timed together –> minimal ischemic time
T/F: The Liver is similar to the heart and kidney and cells dont regenerate
F
A portion of the liver can be donated and actually regenerate close to its normal size before donation.
What things do we need to keep pt hemodynamically stable during liver transplant with brain dead donors?
A line
CVC
PA cath
TEE
What are anesthesia considerations for liver transplant preop?
Preop eval
Vascular access
Blood product availability
What are anesthesia considerations for liver transplant dissection?
Hemodynamic compromise
Hemorrhage
Decreased to Venus return
What are anesthesia considerations for liver transplant anhepatic?
Hemodynamic compromise from IVC clamping
Metabolic acidosis
Hypocalcemia
Hyperkalemia
Hypothermia
Hypoglycemia
What are anesthesia considerations for liver transplant reperfusion?
Hemodynamic instability
Dysrhythmias
Hyperkalemia
Acidosis
PE
Cardiac arrest
What are anesthesia considerations for liver transplant post transplant?
ICU admission
Early/late extubation
Hemodynamic management
T/F: the liver is the largest internal organ in the body
T
