Liver and Renal Tutorial

Question 1

The safest local anaesthetic drug to use, utilising an infiltration technique, for a patient with advanced liver disease in order to remove tooth 35 is:

Answer 1

Articaine.

Question 2

When providing instructions on first line simple analgesia for a patient with liver cirrhosis, which analgesic medication should be recommended?

Answer 2

Paracetamol.

Question 3

The liver is responsible for the production of which clotting factors involved in the coagulation cascade?

Answer 3

Factor 1,2,7,9,10,11.

Question 4

Other than clotting factors, which product of the liver is essential in achieving haemostasis?

Answer 4

Thrombopoetin.

Question 5

What is the minimum UKELD score for an individual to be placed on a liver transplant list?

Answer 5

49.

Question 6

The faeco-oral route is the main route of transmission for what liver disease?

Answer 6

Hep A.

Question 7

What liver disease has circular RNA?

Answer 7

Hep D.

Question 8

Sofosbuvir is a treatment given to clear what virus?

Answer 8

Hep C.

Question 9

Characterised by liver cell necrosis and inflammation, followed by replacement with fibrotic tissue and regenerating nodules of hepatocytes, and vascular derangement- (what liver disease is this)?

Answer 9

Cirrhosis.

Question 10

The Dane Particle is found in the serum of patients infected with what liver disease?

Answer 10

Hep B.

Question 11

Halothane can be responsible for what liver disease?

Answer 11

Drug-induced hepatitis.

Question 12

What liver disease is strongly associated with obesity and diabetes type II?

Answer 12

Non-alcoholic fatty liver disease.

Question 13

What is the name given to the primary malignancy of the liver?

Answer 13

Hepatocellular carcinoma.

Question 14

An arteriovenous fistula is provided in which situations?

Answer 14

Above the wrist for haemodialysis.

Question 15

Match the renal anatomical structure with the most appropriate function:

Actively reabsorbs glucose, amino acids, uric acid and inorganic salts.

Answer 15

Proximal convoluted tubule.

Question 16

Match the renal anatomical structure with the most appropriate function:

Surplus or waste ions and molecules flow out as urine.

Answer 16

Collecting tubule.

Question 17

Match the renal anatomical structure with the most appropriate function:

Water leaves by osmosis.

Answer 17

Loop of henle.

Question 18

Match the renal anatomical structure with the most appropriate function:

Na+ is reclaimed by active transport, with water loss by osmosis.

Answer 18

Distal convoluted tubule.

Question 19

On which day of the week would it be best to schedule dental treatment for a patient who receives dialysis every Monday and Friday?

Answer 19

Tuesday.

Question 20

Which anticoagulant is commonly used in the management of patients who require renal dialysis?

Answer 20

Heparin.

Question 21

What are the potential medical reasons for your inability to achieve homeostasis?

Answer 21

• An undiagnosed bleeding disorder (Haemophilia A and B, lack of factor 8 and 9)
• People on anticoagulants (antiplatelets, heparin (low weight heparin), vit k antagonists is warfarin)
• The patient could drink more than mentioned as this could affect the platelet levels within their body as liver produces clotting factors)
• Patient might have forgotten to tell you about their medical history- blood cancer- myeloma/lymphoma affects how blood clots are produced
• They might be undergoing chemotherapy- supresses bone marrow (not producing as many blood cells as well as they should be)
• reduced clotting factor synthesis
• HIV medications too.

Question 22

How would you manage a patient if they couldn’t achieve haemostasis?

Answer 22

• Pack open socket with haemostatic material and place sutures
• Gauze (wet this first so it doesn’t affect the blood clot), dentist puts pressure on it
• Haemostatic packing material- oxidised cellulose or collagen sponge
• Suture kit (resorbable (2 weeks) and non-resorbable sutures (black silk and proline- 3-7 days patient back and cut it out)), VICRYL sutures dissolve faster
• Surgicel
• Fibrin strips- fibrin stabilised primary platelet plug by crosslinking platelets to each other and damage vessels to prevent further blood loss
• Apply pressure than maybe pack wound
• IF IT DOES NOT STOP= consider phoning local max fax or oral surgery department or A&E, ambulance if a lot of blood
• (cauterize it- stops bleeding by creating a barrier around the tissue by burning soft tissue, bone wax-white soft wax you put on bleeding bone, adrenaline soaked gauze).

Question 23

Symptoms of liver disease?

Answer 23

-jaundice, oedema ascites, mental confusion, swollen ankles, GI haemorrhage, tremors, parotid swelling, weight loss, spider naevi (broken blood vessels), palmer erythema (red lesions), finger clubbing, fatigue etc.

Question 24

In order to assess and manage this person safely, what special investigations are required? List the dental and medical special investigations you wish to request and justify why you are requesting them (patient with liver disease and needs a liver transplant).

Answer 24

• Diagnosing liver failure
• Taking medical history and performing a physical examination, they may then perform a variety of additional tests including:
• Liver blood tests
• Assess the levels of various proteins and enzymes in your blood that can be an indicator of your liver funtions
• Other blood tests
• Complete blood count (CBC) or test for viral hepatitis or genetic conditions that can cause liver damage
• Imaging tests
• Ultrasound, CT scan, or MRI scan can help doctor visualise liver
• Biopsy
• Tissue sample from liver can help doctor see if scar tissue is present and can also aid in diagnosing what may be causing the condition
• Dental special investigations
• Radiographs
• Biopsy of unusual tissues
• BPE, 6PPC if needed
• Check for caries – visual investigation with good lighting
• TTP
• Sensibility tests
• To be dentally fit, want to make sure there is no active disease
• Needs to be dentally fit before operations
• No active disease = caries/endo/perio issues
• Assess then
• PD has to be under control
• Fill caries
• Want to reduce bacteraemia.

Question 25

What are the five stages of liver disease?

Answer 25

1st stage= hepatitis (reversible)
2nd stage= fibrosis (scarring on the liver which builds up and eventually leads to cirrohosis and necrosis of hepatocytes)
3rd stage= cirrhosis (irreversible scarring)
4th stage= end stage liver disease
5th- hepatocellularcarcinoma.

Question 26

What is the UKELD score and what is its importance?

Answer 26

• UKELD is a model for end stage liver disease that predicts survival of patients listed for liver transplants in the UK (helps patients understand their life expectancy, need for transplant and prioritising on the list)
• 49= (10% chance of one-year mortality) the minimum score to consider liver transplant- patient will be on immunosuppressants for the rest of their life so need no possible source of infection.