Liver and Gallbladder (Apex) Flashcards
The ______ is the functional unit of the liver.
lobule
Hepatocytes in zone ____ are most susceptible to ischemic injury
3
_____ cells remove bacteria from portal blood before the blood enters the systemic circulation
Kupffer
Bile is produced by _____ and stored in the _______.
hepatocytes
gallbladder
Bile pathway to duodenum:
canaliculi—> bile duct —> common hepatic duct —-> common bile duct —> ampulla of Vater—> duodenum
_____ and ______ drain into the space of Disse before they enter into the ______ duct.
lymph and proteins
lymphatic
The liver receives SNS innervation from ____-______
T3-T11
There are _______ to _____ lobules in the liver
50,000-100,000
Zone __ has the highest concentration of CYP450 enzymes
3
How much CO does the liver receive?
30% or 1500ml/min from dual blood supply
The portal vein provides ____% of the total liver blood flow and provides ___% of the liver’s oxygen supply.
75%
50%
The hepatic artery provides __% of the total liver blood flow and provides __% of the liver’s oxygen supply.
25%
50%
A decrease is portal vein flow will cause…. How does liver disease affect this?
an increase in hepatic artery flow
severe liver disease impairs this response which makes the diseased liver more susceptible for hypoperfusion
Portal Perfusion = ________ - ________.
Normal portal vein pressure =
Portal Vein pressure - Hepatic Vein pressure
7-10 mmHg
Portal HTN = >20-30 mmHg
Portal HTN reduces blood flow to the liver which produces back pressure on the ______ organs. Vascular engorgment accounts for _______ and ______ in the esophagus, stomach, and intestines.
Splanchic
splenomegaly and varices
Physiologic consequences of Portal HTN include:
ascites, spider angiomas, hemorrhoids, and encephalopathy
Both ______ and ______ reduce MAP and CO which can reduce liver blood flow in a dose-dependent fashion.
GA and neuraxial
Hepatocytes produce: (3)
-Thrombopoietin
-Alpha -1- acid glycoprotein
-Factor 7
Vitamin K is required to synthesize factors…….and proteins……(anticoagulant)
2,7,9,10 (procoagulants)
S,C,Z (anticoagulants)
Factor 8 is produced by the liver ______ cells and ______ cells (not by hepatocytes)
sinusoidal cells
endothelial cells
______ is a reservoir for acidic drugs.
Albumin
________ glycoprotein is a reservoir for basic drugs.
Alpha-1-acid glycoprotein
The liver produces all plasma proteins except for ______.
immunoglobulins (gamma globulins)
The liver clears ______ from the circulation which makes patients with liver failure at risk for ______.
insulin
hypoglycemia
The liver converts ammonia to ____ which is eliminated by the ____.
urea
kidney
Failure to clear ______ leads to hepatic encephalopathy.
ammonia
Old RBCs are broken down by the _______ cells in the ______.
reticuloendothelial cells
spleen
Spleen: Hemoglobin——> _______—->_______
heme —-> unconjugated bilirubin (neurotoxic)
What coagulation Factors are NOT produced in the Liver?
von Willenbrand factor (vascular endothelial cells)
Factor 3 (vast. endothelial cells)
Factor 4 (calcium comes from diet)
Glucose is stored as glycogen =
Glucogenisis
Glycogen is cleaved into glucose:
Glycogenolysis
Glucose is created from non-carbohydrate sources (magically)
Gluconeogensis
Test for Hepatocellular injury:
AST (10-40 units/L)
ASL (10-50 units/L)
Test for Synthetic Function:
PT (12-14 secs)
Albumin (3.5-5.0 g/dL)
Test for Hepatic Clearance:
Bilirubin (0-11 units/L)
Test for Biliary duct obstruction:
Alkaline phoshatase
__________ _____ is very sensitive for acute hepatic injury because Factor __ has a half-life of only __-__ hours.
Prothrombin time
7
4-6 hours
The _____ ___ ____ controls the flow of bile released from the common hepatic duct.
Sphincter of Oddi
______ of the sphincter of Oddi increase biliary pressure. Caused by ____.
Contraction
Opioids
(more potent = greater increase in biliary pressure)
Hypercapnea and acidosis causes ………
increased liver flow
Pre-hepatic jaundice is caused by _____ ______.
increased hemolysis
Hepatic jaundice is caused by ____ ____.
liver impairment
Post-hepatic jaundice is caused by:
a blockage of bile ducts
AST/ALT ratio > __ suggests cirrhosis or alcoholic liver disease
2
Hepatitis ___ is the most common form of viral hepatitis. oral-fecal route.
A
Chronic hepatitis is characterized by hepatic inflammation that exceeds ____ months.
6
Antidote for acetaminophen overdose
Oral N-acetylcysteine
Most common cause of chronic hepatitis. Second most common?
alcoholism
2nd = hepatitis C
S/S of chronic hepatitis
jaundice, fatigue, thrombocytopenia, glomerulonephritis, neuropathy, arthritis, myocarditis
Chronic Hepatitis: ___ is prolonged and ____ is decreased
PT
albumin
Hepatotoxic drugs that inhibit CYP450
-tylenol
-halothane
-amio
-antibiotics (pcn, tetracyclines, sulfonamides)
Max dose of Acetaminophen
Tx?
4g in 24hrs
Tx= N-acetylcysteine
Acutely intoxicated patient anesthetic considerations:
-decrease MAC (increase in chronic)
-aspiration precautions
-alcohol inhibits NMDA receptors
-alcohol impairs pharyngeal reflexes
Cirrhosis has a reduction in the # of functional ______ and ______.
hepatocytes and sinusoids
MELD score predicts _____ mortality with patients with ESLD
90 day
MELD- three factors that measure hepatic function:
Score (low, intermediate, high risk)
bilirubin, INR, serum creatinine (BIC)
Low risk= <10
Intermediate = 10-15
High = >15
Volatile agents preferred for Liver Disease:
Iso and Sevo (less decrease in hepatic blood flow)
Halothane bad for liver! (halothane hepatitis)
Muscle relaxant drug of choice for liver disease
Cistatricurium
TIPS procedure bypasses a portion of the hepatic circulation by shunting blood from the ______ vein (inflow) to the ____ vein (outflow).
portal vein
hepatic vein
TIPS procedure reduces:
Main risk?
portal pressure
back pressure on splanchin organs
reduces likelihood of bleeding from esophageal varicose
ascites
Main risk= hemorrhage
Severe liver disease impairs the liver’s ability to clear ________ substances from systemic circulation. This leads to a _______ circulation (_______ + ______)
-vasodilating
-high cardiac output
-low SVR
The common bile duct and pancreatic duct form the_______ which leads to the ________
Ampulla of Vater
Sphincter of Oddi
You can relax the sphicter of Oddi with……..
-glucagon, naloxone or nitroglycerin
-glycopyrolate and atropine
Biliary stones cause obstruction of bile. If these substances can’t move into the ______ ______ they back up into the _____ and ______.
small intestine
liver and pancrease
How much bile does the gallbladder hold?
30-50cc
3 main functions of Bile
Emulsify and enhance absorption of ingested fats and fat-soluble vitamins.
Provide an excretory pathway for bilirubin, drugs, toxins, and immunoglobulin A (IgA)
Maintain duodenal alkalization
Cholecystitis characteristics and s/s:
Acute obstruction of the cystic duct
-Patients present with acute, severe, midepigastric pain that often radiates to right abdomen.
Labs for Cholecystitis
increase in plasma bilirubin, alkaline phosphatase, amylase, and WBCs.
Cholecystitis: Free abdominal air suggests?
ruptured viscus with perforation of gallbladder. (Free air = emergency ex-lap)
Cholelithiasis /Choledocholithiasis=
Acute obstruction of the common bile duct.
Cholelithiasis /Choledocholithiasis: Charcot triangle
fever, chills, upper quadrant pain
Surgical treatment for Choledocholithiasis (stones in the common bile duct)
ERCP (endoscopic retrograde cholangiopancreatography)
Cholecystectomy Anesthesia Considerations:
Post-op pain
Nausea and vomiting
Peritoneal irritation from CO2
Intravascular volume restoration
Cholecystectomy: Open approach involves a _____ upper quadrant abdominal incision which will _____ lung volume and _____ pain.
right
decrease
increase
______ duct and the ______ duct join the common hepatic duct before it empties into the ______
cystic duct
pancreatic duct
duodenum
