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DEN303 - IHD > Liver and Gall Bladder Disease > Flashcards

Liver and Gall Bladder Disease Flashcards

Demonstrate knowledge of the function of the liver in metabolism, synthesis and excretion. Describe the common causes of pre-hepatic, hepatic and post hepatic jaundice. Recognise jaundice and the peripheral signs of chronic liver disease. Demonstrate knowledge of liver and biliary tract disease such as viral hepatitis, drug-induced hepatitis, cirrhosis, gallstones and tumours of the bile duct and pancreas Demonstrate knowledge of the ways in which liver disease creates risks during dental su

1
Q

3 circulations through liver

A

Arterial and venous
Portal - between liver and pancreas and kidneys and rest of body
Bile flow

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2
Q

Bile flow description

Why reabsorbed?

A

Produced in liver as bile salts
Bile stored by gall bladder
Released into duodenum to break down lipids
Bile acids reabsorbed in terminal ileum and reenter circulation
Energy efficient
Return to liver and then gall bladder

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3
Q

Micro anatomy

A

Lobules with central hepatic vein

Hexagonal triads in corner

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4
Q

Fx of liver (7)

What happens if fat metabolism is not functional

A

Detoxification - filters and cleans blood of metabolic waste
Immune functions - fights infections and disease
Synthesis of clotting factors, proteins, enzymes, glycogen and fats
Production of bile and breakdown of bilirubin
Energy storage (glycogen and fat)
Regulation of fat metabolism
Fatty liver occurs - too much fat for function - asymptomatic
Ability to regenerate cells

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5
Q

Metabolic role of liver
When does this role vary?
How is the liver regulated?

A

Maintains continuous supply of energy for the body
Controls metabolism of cholesterol and fats

Fasting, digestion, absorption and metabolism
Multiple pathways

Endocrine glands
Nerves

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6
Q

Liver injury categories and different types

Chronic definition

A 
Time line - acute/chronic 
Ongoing for more than 6 months 
Pattern - hepatic/cholestatic/mixed 
Presentation - symptomatic/asymptomatic
Severity - cirrhotic/non-cirrhotic
Cause
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7
Q

Types of liver injury - acute

Outcomes and causes

A

Recovery
Acute liver failure

Viral (A, B, E, EBV)
Drugs
Vascular

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8
Q

Types of liver injury - Chronic

Outcomes and causes

A

Recovery
Cirrhosis - (varices, hepatoma)
Chronic liver failure - decompensated

Alcoholism
Viral (B, C)
Autoimmune
Vascular metabolic

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9
Q

Presentation of liver injury - acute

A

Asymptomatic
Abnormal LFTs and coagulopathy
Malaise, nausea, anorexia
Jaundice

CONFUSION - suggests failure rather than disease

Rarer - bleeding and liver pain

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10
Q

Presentation of liver injury - CHRONIC

A 
Abnormal LFTs 
Hepatomegaly
Malaise, abdo pain
Itching 
Oedema 
Varices 
Bruising easily (coagulopathy) 
Confusion
Cachexia - anorexia 
Jaundice
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11
Q 
LFTs
Comprised of? 
ALP
GGT
ALT
AST
Normally functional if....

Which two tests are actually effective

What is slightly reduced in cirrhosis/elevated and important to test in case of

A 
Liver Function Tests 
Albumin 
ALP - alkaline phosphatase 
GGT - gamma GT
ALT - alanine aminotransferase 
AST - aspartate aminotransferase 
Bilirubin 
Globulin 
Normal LFT and PT and platelet count

Albumin and bilirubin indicate ability of liver to synthesise products

Platelet count and INR/PT time
Excessive bleeding

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12
Q

Jaundice due to?

A

Increased bilirubin as liver fails to break it down
Scleral jaundice first noticed
Mild jaundice can be difficult to spot

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13
Q

Bilirubin metabolism
Where
Excreted how
What happens to faeces if not excreted

A 
Breakdown product of haemoglobin - usually conjugated in liver 
Metabolised in liver
Excreted via intestine and really 
Motion is pale if not 
Can be interrupted at several points
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14
Q 
Causes of jaundice 
3 types (at which point)
A

Pre-hepatic
Hepatic
Post-hepatic

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15
Q

Causes of jaundice - pre-hepatic

A

Haemolysis due to increased substrate

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16
Q

Causes of jaundice - hepatic

A

Intrinsic liver disease
Cirrhosis
Infiltration of liver by tumours e.g hepatoma
Acute hepatitis (viral, alcoholic, autoimmune, drug related)

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17
Q

Causes of jaundice - post hepatic
Examples
Examples of external compression

A

Obstruction of biliary outflow
Gall stones
External compression - pancreatitis, lymphadenopathy, pancreatic tumour

18
Q

Liver disease - most common causes

A

Alcohol
Non alcoholic steatohepatitis NASH
Viral hepatitis (B, C)

19
Q

Liver disease - less common causes and examples

A

Auto-immune - hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis

Metabolic - haemochromatosis, Wilson’s, a1 antitrypsin deficiency

Vascular - Budd-Chiari, portal vein thrombosis

Drugs
Amiodarone
Chemotherapy

20
Q

Liver disease - alcoholic

A

Common cause of cirrhosis

Deaths rising

21
Q

Non-alcoholic fatty liver disease
Risk factors
LFTs
Affects who

A

Obesity, diabetes, hypertension, dyslipidaemia
LFTs normal maybe
20% of western popn

22
Q

Chronic viral hepatitis
Caused by?
Transmitted through?

A

Hep B/C
Blood and body fluids
1/3 people exposure to one or both

23
Q

Hepatitis B

Features

A 
DNA virus 
Reads in hepatocyte genome 
Persists in liver 
Can reactivate 
Intercourse/vertically
Vaccination available 
Longterm treatment
24
Q

Hepatitis

A 
RNA virus 
IVDA
Reinfection possible
Time limited treatment but 90% cure 
No vaccine
25
Q

Stages of chronic liver disease
NCPH definition and due to?
Pre-cirrhotic
Liver cirrhosis

A

Non cirrhotic portal hypertension - due to hepatic vascular problems - good clotting - rare

Pre-cirrhotic - no effect dental work - asymptomatic sometimes
Liver cirrhosis

26
Q

Cirrhosis of liver
Result of
Mechanisms
Increased

A

Chronic longstanding liver damage
Scar tissue replaces healthy tissue beyond healing due to varices (enlarged blood vessels)
Liver architecture disrupted
Resistance to blood flow through liver –> portal hypertension

27
Q

Identifying liver cirrhosis

two types

A

Compensated

Decompensated

28
Q

LC - compensated

A

Invisible
Normal bloods
Low risk

29
Q

LC - decompensated (failure of organ to cope with overload following disease)

A

Visible - jaundice
Abnormal blood loss
Risks high

30
Q

Complications of chronic liver disease
Acute and chronic complications
Ascites?
Portal hypertension

A

GI bleeding
Ascites - build up of fluid in abdomen AKA portal hypertension

Thrombocytopenia

Jaundice

Hepatic encephalopathy

Renal impairment

Coagulopathy

Infection

Malnutrition and bone disease

31
Q

Hepatocellular carcinoma
Occurs in ?
Why

A

Can complicate liver cirrhosis
Hep B in pre cirrhotic liver disease
Oncogenic virus - leading cause of liver cancer

32
Q

Signs and symptoms of chronic liver disease

A 
PALMER ERYTHEMA 
SPIDER NAEVI (advanced disease)

GYNAECOMASTIA - low testosterone/drug related spironolactone

LEUCONYCHIA - white nails
Fingernail clubbing due to oedema

JAUNDICE - sign of decompensation - first visible in eyes - sign of decompensation in chronic liver disease

ASCITES - swelling of lower abdomen

33
Q

Hepatic encephalopathy

Can be confused with?

A

Feature of decompensation
Difficult to spot
Overt confusion in patient
Indicates underlying issue

Acute alcohol withdrawal

34
Q

Recognising HE

A

Confusion
Altered behaviour
Coma
Collateral history

35
Q

Testing for HE

A

Neurological tests

36
Q

Treatment of liver disease - symptomatic

A

Diuretic
Nutritional support
Supplements
Propanolol

37
Q

Treatment of liver disease - specific

A

Antiviral
Immunosuppression
Relieving obstruction
Venesection

38
Q

Dental considerations

A 
Comprehensive history 
Lab investigations - FBCs, PT, LFTs 
PT and Platelets are most useful test 
Consult physician 
Minimise soft tissue trauma 
Consider hospital setting for advanced procedures or pts with coagulopathies 
Hep B
Increased bleeding in patients with liver disease
39
Q

Dental considerations - prescriptions

anti platelet consumption

A

Avoid liver metabolised meds e.g anaesthetics, aspirin has to stop 1 week before Tx, Sedatives
Increased risk of drug toxicity e.g NSAIDs

40
Q

Alcohol limits

Weekly

Harmful

Hazardous

Binge drinking

What is one unit

A

14 units

15-28 units

> 28 units

> 10 units for men and > 7 units in one session for women
1/2 pint

41
Q

Hep C prevalence

A

<1%
IV drug use
Medical treatment abroad
Foetal transmission less likely than in Hep B

DEN303 - IHD (58 decks)

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