Liver 4 Flashcards
Common physiologic changes in the patient with cirrhosis include all of the following EXCEPT:
a. respiratory acidosis
b. increased cardiac output
c. right-to left shunt
d. decreased GFR
a. respiratory acidosis
Cirrhosis is characterized by
cell death where nodules and fibrotic tissue replace healthy hepatic tissue
Cirrhosis reduces the number of
functional hepatocytes as well as the number of sinusoids
Why does portal hypertension occur with cirrhosis?
the number of blood vessels passing through the liver is also reduced which creates portal hypertension
The following can be used to predict the risk of perioperative mortality with cirrhosis:
the MELD score & child-pugh class
Severe liver disease impairs the liver’s ability to
clear vasodilating substances from the systemic circulation
The liver’s impedance to clearing vasodilating substances from the systemic circulation leads to
a hyperdynamic circulation (high cardiac output & low SVR)
______________ introduces a stent between the portal vein and hepatic vein to bypass an increased hepatic vascular resistance
A transjugular intrahepatic portosystemic shunt (TIPS procedure)
____________ is a significant risk of a TIPS procedure
Hemorrhage
Etiologies of cirrhosis include
non-alcoholic fatty liver disease
alcohol abuse
alpha-1-antitrypsin deficiency
biliary obstruction
chronic hepatitis
right-sided heart failure
hemochromatosis
Wilson’s disease
The most common cause of liver disease is
non-alcoholic fatty liver disease
Hemochromatosis causes
iron overload
Wilson disease is
genetic (copper accumulates in the tissues)
Right-sided heart failure leads to
increased hepatic vascular resistance
Biliary obstruction and chronic hepatitis lead to
inflammation and tissue destruction
Alcohol abuse and non-alcoholic fatty liver disease lead to
fatty infiltration
To partially offset the increased resistance, the body creates collateral vessels that bypass the liver, these are called
portosystemic shunts
A patient is at increased risk of perioperative morbidity and mortality if their Child-Pugh score is
C
a patient is at increased risk of perioperative morbidity and mortality if their MELD score is
> 15
A MELD score of ______- is an intermediate risk
10-15
The MELD score predicts
90 day mortality in patients with ESLD
The MELD score uses
logarithmic calculation of hepatic function: bilirubin, INR, and serum creatinien
The Child-Pugh score examines the following five factors:
albumin
PT
bilirubin
ascites
encephalopathy
A Class C Child-Pugh score has a
80% risk of perioperative mortality
A class B Child-Pugh score has a
30% risk of perioperative mortality
Cardiovascular changes that accompany ESLD include
hyperdynamic circulation
portal hypertension (esophageal varices, splenomegaly)
ascites
Pulmonary changes that accompany ESLD inclue
restrictive defect
respiratory alkalosis
hepatopulmonary syndrome (Right to left shunt)
portopulmonary hypertension
CNS changes that accompany ESLD include
hepatic encephalopathy
Autonomic changes that accompany ESLD include
increased SNS and RAAS
Renal changes that accompany ESLD include
renal hypoperfusion
hepatorenal syndrome (renal failure)
Hematologic changes that accompany ESLD include
anemia
reduce factor production
thrombocytopenia
What is a TIPS procedure?
it reduces portal pressure by shunting blood from the portal vein to the hepatic vein
Match each phase of liver transplantation with its MOST likely complication:
pre-anhepatic phase
anhepatic phase
neohepatic phase
hyperkalemia
pulmonary aspiration of gastric contents
profound reduction of cardiac output
pre-anhepatic phase- pulmonary aspiration of gastric contents
anhepatic phase- profound reduction of cardiac output
neohepatic phase- hyperkalemia
The most common indication for liver transplant is
hepatitis C
Other common indications for liver transplant include
alcoholic liver disease
malignancy
The surgical procedure of liver transplant can be divided into the following phases
pre-anhepatic phase
anhepatic phase
neohepatic phase
Post-reperfusion syndrome is defined as
systemic hypotension more than 30% below baseline for at least 1 minute during the first 5 minutes of reperfusion of the donor liver
Treatment of post-reperfusion syndrome is
supportive
vasopressors
correcting electrolyte abnormalities
correcting acid-base
Preoperative considerations for liver transplant include
ensure adequate supply of blood products
patients are coagulopathic so careful during invasive procedures (NGT, a-line, etc.)
hepatic encephalopathy–> avoid anxiolytic
Hyper or hyponatremic d/t volume overload & sodium retention
If the patient has esophageal varices, can you still do TEE?
yes as long as transgastric views are avoided
If the patient suffers from hepatic encephalopathy,
then avoid anxiolytic premedication
The pre-anhepatic phase begins with
surgical incision
The pre-anhepatic phase ends with
cross-clamping of the portal vein, hepatic artery, and IVC
Surgical objectives of the pre-anhepatic phase include
surgical incision
mobilization of liver structures
mobilization of vascular structures
isolation of bile duct
