Liver- disease

Question 1

Name the 4 lobes of the liver.

Answer 1

Right

Left

Quadrate

Caudate.

Question 2

What is the function of the gallbladder?

Answer 2

Storage of bile

Question 3

What is the function of the common bile duct?

Answer 3

Connects the gallbladder to the pancreas and transports bile to the duodenum.

Question 4

What is the function of the pancreas?

Answer 4

produces digestive enzymes.

Question 5

What is Jaundice?

Answer 5

The accumulation of bilirubin in the circulation

Question 6

What is bilirubin?

Answer 6

A natural product of Haem breakdown which should be in a low level in the blood.

Question 7

What happens if there is a high level of bilirubin in the blood?

Answer 7

• Bilirubin spreads to the skin and accumulates causing yellow skin.
• Bilirubin irritates the nerve endings causing itching.

Question 8

How is bilirubin excreted?

Answer 8

It is conjugated by hepatocytes which makes it soluble & able to be excreted.

Question 9

Discuss the types of jaundice?

Answer 9

Pre hepatic- Increased haem load

Hepatic - failure of the liver conjugating the bilirubin

Post hepatic- a blockage of bilrubin removal.

Question 10

Describe pre-hepatic jaundice

Answer 10

Too much bilirubin overloads the livers ability to conjugate it. This results in more unconjugated bilirubin passing in the blood.

Question 11

Describe how haemolytic anaemia causes pre-hepatic jaundice?

Answer 11

There is more red blood cells being broken down quicker than they should be increasing the volume of bilirubin in the blood.

Question 12

Explain how the mixing of blood at birth causes jaundice? (neonatal cause)

Answer 12

The baby’s Blood cells attack and breakdown the mother’s blood cells. Leaving Increased bilirubin in the blood.

Question 13

What is Kernicterus?

Answer 13

Brain damage due to excessive bilirubin deposits in the brain.

Question 14

Why do we use blue light therapy to treat jaundice babies?

Answer 14

The blue light breaks down the bilirubin that has accumulated on the skin surface.

Question 15

Describe causes of hepatic jaundice?

Answer 15

• Less hepatic cells- so less Bilirubin is conjugated
• imapaired enzyme action- so less liver cells can conjugate the bilirubin.
• failure of secretion- Bilirubin is conjugated fine, but the cell membrane is impermeable to conjugated bilirubin .

Question 16

Describe post hepatic jaundice?

Answer 16

This is due to an obstruction in the billary outflow. A blockage in the biliary tree when bile is added results in a backing up of conjugated and unconjugated bilirubin .

Question 17

What is Primary biliary sclerosis?

Answer 17

Autoimmune destruction of the bile duct causing buildup in the liver.

Question 18

How can a pancreatic carcinoma cause post hepatic jaundice?

Answer 18

The tumour squeezes the bile duct and obstructs it

Question 19

What is a Cholangiocarcinoma?

Answer 19

A tumour of the bile duct .

Question 20

What does the dark colour of urine mean?

Answer 20

That the bilirubin in the body has been conjuagated.

Question 21

The patient has dark urine and pale stool.

What type of jaundice has caused this? Explain

Answer 21

post-hepatic.

The dark urine- bilirubin is conjugated and can make it to the kidney for excretion.

Pale stool- conjugated bilirubin cannot make it to the intestine

Question 22

The patient has dark urine and dark stool.

What type of jaundice has caused this? Explain

Answer 22

Pre hepatic jaundice, as the bilirubin has been conjugated, but there is too much bilirubin produced causing the build up.

Question 23

The patient has pale urine and pale stool.

What type of jaundice has caused this? Explain

Answer 23

Hepatic jaundice- the bilirubin has not been conjugated, therefore there is no pigment in the urine or stool.

Question 24

How do you treat Post hepatic jaundice?

Answer 24

• Deal with the gallstones:
• Remove the gallstones by ERCP
• Remove the gallstones by breaking them up using lithotrispy
• Force open the channel using a stent (allowing the jaundice to settle before you decide what next)
• Preventing gallstone reoccurence

Question 25

How do you prevent gallstone production?

Answer 25

Removal of the gall bladder (cholecystectomy- no longer able to eat fatty foods) Prevent bile build up (using medications or altering diet) Use colestryamine to prevent bile resorption from the GIT.

Question 26

What effect do gallstones have?

Answer 26

They block the bilary tree Cause inflammation of the gallbladder (acute cholecystitis)

Question 27

What are the symptoms of a gallstone?

Answer 27

Pain in the shoulder. Abdominal pain on the right side. Pain when eating fatty foods.

Question 28

What are acute liver diseases?

Answer 28

Acute liver disease is when there is a sudden loss of liver function causing rapid death by: Bleeding- patient cannot produce more clotting factors once the store has been deplete d Encephalopathy- damage to the brain due to toxic materials.

Question 29

What is cirrhosis?

Answer 29

Mixed damage fibrosis and regeneration of the liver structure which results in an accumulation of damage meaning fewer hepatocytes can eliminate the waste material.

Question 30

What are the signs of cirrhosis?

Answer 30

* Portal hypertension-Blood passing through the oesophagus joining vein producing oesophageal varices which can burst * Jaundice * Oedema and ascites * Encephalopathy- when the liver does not detoxify what you eat * palmar ertheyma and spider navi

Question 31

What are these? and what are they caused by?

Answer 31

Spider navi which are enlarged blood vessels. These are caused by high oestrogen levels.

Question 32

What is this and what causes it?

Answer 32

Ascites which is build up of fluid in the abdomen due to liver failure. Causing High portal venus pressure. Low plasma protein synthesis Low oncotic pressure.

Question 33

What is this and what is it caused by?

Answer 33

Palmar erythema This is caused by enlarged blood vessels due to the high oestrogen levels

Question 34

What are the two functions of the liver and what happens to them when the liver fails?

Answer 34

metabolic and synthetic. These are lost in liver failure.

Question 35

What effect does the loss of synthetic function of the liver have?

Answer 35

Liver does not produce clotting factors (concern if taking out teeth) Does not produce plasma proteins: * Transporting proteins * Gamma globulin.

Question 36

In liver failure, what processes are affected when we loose metabolic function?

Answer 36

Loss of: Drug metabolism- no first pass mechanism ( so drug dose needs to be altered) Detoxification Conjugation of RBC breakdown products (causing jaundice)

Question 37

How do we test liver function?

Answer 37

The INR- internal normalised ratio. This measures prothrombin time (time taken to convert prothrombin to thrombin) It should be 1 (unless patient is on warfarin)

Question 38

What should you ask if you don't know how bad a patient's liver problem is?

Answer 38

Do they have a specialist doctor for their liver problem?

Question 39

What are the metabolic consequences for the patient of liver disease? What does this cause?

Answer 39

They will have abnormal drug metabolism This will cause: * Prolonged effect of sedative (so avoid IV) * Need to reduce drug dosage. * Cannot give patient's tetracycline.

Question 40

What is the most suitable analgesic for a patient with liver disease?

Answer 40

Paracetamol .

Question 41

Why do you not give a liver disease patient NSAIDs ?

Answer 41

NSAIDs increase bleeding risk.

Question 42

Why are local anaesthetics not a problem for patient's with liver failure?

Answer 42

They are metabolised in the plasma- not the liver.

Question 43

Why does the gallbladder cause pain in the shoulder.

Answer 43

Inflammation of the gallbladder causes irritation of the diaphragm and the phrenic nerve. This supplies to skin on the shoulder.

Question 44

What is the main blood supply of the liver?

Answer 44

Hepatic portal vein

Question 45

Compare the dental treatment of patients with moderate liver disease to those with severe liver disease?

Answer 45

Moderate liver disease : Platelet count \>100 Only one blood cell type is affected. Can treat patient normally but pack the area after an extraction. Severe liver disease: Abnormal blood results. Difficulty with haemostasis (Stopping bleeding) Need a haemotologist present to treat (hospital)