Liver Disorders Flashcards
1
Q
List indicators of decreased liver function that can be seen on bloodwork
A
- Hypoalbuminemia
- Hypocholesterolemia with end stage liver disease
- Hypoglycemia (when 75% loss of liver function)
2
Q
List the cholestatic enzymes
A
ALP and GGT
3
Q
What increased liver enzymes are always significant in cats?
A
ALT and ALP
Very short half life in cats, if elevated indicates acute liver injury
4
Q
What drugs can cause an increase in ALT?
A
- Phenobarbitol / Barbituates
- Corticosteroids
5
Q
What is different with ALP in cats vs dogs?
A
- Cats lack steroid induced ALP isoenzyme, steroid hepatopathy only happens in dogs!!!
- ALP is always significant in cats, very short half life
6
Q
What can be seen on bloodwork with post hepatic jaundice?
A
- Hyperbilirubinemia
- Hypercholesterolemia
- Increased ALP (higher than ALT)
- Increased GGT
- Mild to mod increases in ALT, AST
7
Q
When is hypoglycemia seen with liver disease?
A
when 75% of hepatic function is lots
chronic, end stage liver dz
8
Q
At what times, pre and post prandial should bile acids be measured?
A
measure pre and 2 hours post prandial
9
Q
Increases in serum bile acid concentration can be seen with?
A
- Hepatic dysfunction
- Portosystemic shunts
- Cholestasis
10
Q
When would running a bile acids test be considered unnecessary?
A
Don’t run bile acids if BILIRUBIN is high on bloodwork …. you can assume bile acids is high if tbili is high
11
Q
How is ammonia produced in the GI tract?
A
- Urease producing bacT
- Bacterial protein degradation
- Enterocyte conversion of glutamine to glutamate
12
Q
How is ammonia detoxified into urea?
A
- Liverrr converts ammonia to urea
- Also detoxified by conversion of glutamate to glutamine in muscle, brain, kidney, and liver
13
Q
What are causes of increased ammonia?
A
- PSS
- Hepatic failure
- Urea cycle deficiency (arginine deficiency in anorexic cats
14
Q
What is an important consideration when collecting a blood sample to measure ammonia levels?
A
- Have to run sample ASAP
- Result will be falsely elevated if left sitting
15
Q
List CS of liver disease
A
- Jaundice
- Ascites
- Anemia
- PU/PD
- Vomiting / Diarrhea (Extra GI cause of SI diarrhea)
- Coagulopathy
- Hepatic encephalopathy
16
Q
Clinical icterus is visible when the bilirubin concentration exceeds ________
A
2-3 mg/dL
17
Q
What are common causes of ascites secondary to liver disease?
A
- Intrahepatic portal venous hypertension MOST COMMON
- Reduced albumin & ↓ oncotic pressure
- RAAs activation, Na+ and water retention worsens ascites
18
Q
When is abdominocentesis indicated for treating ascites secondary to chronic liver disease?
A
- Reserved for patients with discomfort due to the ascites or dyspnea / respiratory distress
- Repeated ABDcentesis can further worsen protein loss
19
Q
What is the treatment protocol for a patient presenting with ascites secondary to chronic liver disease?
A
- Spironolactone (Aldosterone antagonist, K+ sparing, diuretic of choice)
- Low Na+ diet
- Abdominocentesis only if uncomfortable or in respiratory distress, avoid repeated taps
20
Q
Which of the following clotting factors is not produced by the liver?
A. Factor IX
B. Factor III
C. Factor VIII
D. Factor X
A
C. Factor VIII
Liver makes all clotting factors EXCEPT Factor VIII
21
Q
What anti-clotting proteins are produced by the liver?
A
- AT III
- Protein C
- Protein S
22
Q
Why is the assessment of bleeding risk in liver disease patients so challenging?
A
- Hypo, hyper, or normocoagulable states
- Liver produces clotting factors (hypocoagulable state), but also anti-clotting factors (hypercoagulable state)!
23
Q
What is the treatment protocol for patients with coagulopathies secondary to liver disease?
A
- Fresh frozen plasma, pRBCs, whole blood
- Vitamin K
- DDAVP
- Indicated when spontaneous or procedure induced bleeding, no evidence to recommend prophylactically
24
Q
How is the GI tract affected by hepatic disease?
A
- Risk factor for GI ulceration and bleeding
- Splanchnic congestion and poor blood flow may contribute
25
What is the treatment protocol for a patient with CS of GI bleeding secondary to hepatic disease?
- Omeprazole
- Sulcralfate
-
**AVOID ulcerogenic meds like NSAIDS and Pred**
26
How can liver disease lead to PU/PD?
- **Low Urea** (medullary washout)
- **Thirst** (manifestation of hepatic encephalopathy)
- **Excess cortisol secretion**
27
How can severe liver disease result in secondary infections?
- Results in immune dysfunction, increased risk of bacterial translocation, endotoxemia, septic peritonitis if biliary rupture
28
What are the 3 clinical scenerios which can cause hepatic encephalopathy?
**- Acute severe total hepatic failure
- Chronic HE (most commonly from PSS)
- Deficiency in essential AAs in CATS & development of hepatic lipidosis (IMPT!)**
29
True or False: Seizures are the most common clinical sign seen with hepatic encephalopathy
FALSE - rarely have seizures
30
What CS can be seen with hepatic encephalopathy?
- Episodic with fluctuations between stages
- Staring, decreased mentation
- Ataxic
- Head pressing
- Blindness
- Rarely seizures
31
What are precipitating factors for Hepatic Encephalopathy?
- **GI bleeding**
- Excessive protein intake
- Infection
- **Drugs: Benzos, opioids**
- Hyponatremia, Hypokalemia
- Metabolic alkalosis
- Renal failure
- Dehydration
- Constipation
- Overzealous use of Furosemide
32
What is the treatment protocol for acute hepatic encephalopathy?
- ID and remove underlying cause
- **Levetiracetam 1st line for seizures**
- Mannitol or Hypertonic saline for tx of increased ICP
- **Warm water enema followed by lactulose retention enema**
33
What is the treatment protocol for chronic hepatic encephalopathy?
- Soy based (high protein) diet
- Lactulose
**Antibiotics NOT indicated for long term use**
34
What medication can be used to decrease blood ammonia levels in patients with hepatic encephalopathy?
**- Lactulose
- Acidifies colon to convert ammonia into non-absorbable, ionized form
- Increases colonic motility which decreases ammoniagenic colonic microflora
- Decreases #'s of urease producing bacteria in lower GI tract**
35
Clinical signs of acute liver failure are visible when ___________
> 70% of liver function is lost
36
What blood work changes can be seen with acute liver failure?
- Hyperbili
- Decreased BUN, Albumin, Cholesterol, etc
- **PT > 1.5x the upper reference range**
- +/- hepatic encephalopathy
37
What is the treatment protocol for a patient presenting with evidence of acute hepatitis?
- Neutraceuticals (Denamarin/SAMe)
- Gastroprotectants like Omeprazole
- IVFT
- Vitamin K (for coagulopathies)
- Abx ONLY if evidence of infection!
- Treat HE
38
What drugs are most associated with **idiosyncratic hepatotoxicosis**?
- **Carprofen**
- **Methimazole**
- Diazepam
- Sulfonamides
- Mitotane
- Zonisamide
(occurs even at standard doses)
39
What drugs are most associated with dose dependent hepatotoxicosis?
- **Acetaminophen**
- **Phenobarbital**
- Aflatoxin
- Azathioprine
- CCNU
- Azole antifungals
- Xylitol
40
Why are cats more sensitive to acetaminophen toxicity than dogs?
Glucuronyl transferase deficiency, inability to convert to non-toxic metabolite
41
What clinical signs can be seen in cats with acetaminophen toxicosis?
- **Cyanosis**
- **Pale to muddy brown MM's**
- Hematuria and hemoglobinuria (AKI)
- Respiratory distress (hypoxia)
- **Facial or paw edema**
- Icterus
- Hepatic encephalopathy
- CV shock
- Death
(CS of hemolytic anemia)
42
What is the treatment protocol for a patient presenting with evidence of acetaminophen toxicity?
- **N-Acetylcysteine / NAC (1st line Antidote of choice) using a 0.22 um filter**
- Supportive care
- Transition to oral Denamarin once stable
43
What parasitic fluke is a differential for infectious liver disease in dogs?
- Heterobilharzia americana
Results in granulomatous inflammation of the intestinal wall and/or chronic hepatic fibrosis
44
How is infectious liver disease due to Heterobilharzia americana treated?
- **Praziquantel and Fenbendazole**
45
How is infectious liver disease due to suspect Heterobilharzia americana diagnosed?
- Fecal PCR is best
- eggs in Fecal smear or float
- Biopsy from liver or GI tract
46
What is reactive hepatopathy?
Liver damage secondary to disease elsewhere
(GI, pancreas, heart, anemia, endocrine disease)
47
Define vaculolar hepatopathy
Liver syndrome where hepatocytes become swollen with fat, glycogen, or water
**Most common secondary metabolic hepatopathy in dogs and cats**
48
List causes of vacuolar hepatopathy due to glycogen accumulation
- Steroid hepatopathy **DOGS only**
- Vacuolar hepatopathy in scottish terriers
- Cobalamin deficiency in dogs
- Secondary to hepatic insult from another disease process
49
List causes of vacuolar hepatopathy due to fat accumulation
- **Feline hepatic lipidosis**
- Aflatoxin in dogs
- Hypervitaminosis A in cats
- Familial hyperlipidemia
- Secondary to endocrine disease (HypoT, HyperT (occasionally), DM)
50
What is a common cause of liver disease in scottish terriers?
**Progressive vacuolar hepatopathy associated with hepatocellular carcinoma**
51
What is cirrhosis?
- End stage chronic hepatitis
- Occurs when substantial architectural distortion, fibrosis, and portal hypertension are present
52
What is needed to definitively diagnose a patient with chronic hepatitis?
- **Biopsy required**, laproscopic is best
Can't diagnose chronic hepatitis with FNA!!
53
What is the treatment protocol for a patient with chronic hepatitis?
- Hepatoprotectants (Denamarin/SAMe)
- Immunosuppressive trial with Cyclosporine only after biopsy and histological evidence to R/O neoplasia… used to differentiate immune-mediated CH from idiopathic CH
54
How can you differentiate immune-mediated chronic hepatitis from idiopathic chronic hepatitis?
- Requires an **immunosuppressive trial with Cyclosporine** to differentiate (only done after biopsy results)
55
What are causes of Copper storage disease?
- Altered copper excretion in bile
- Excessive dietary intake
- Or both
56
What dog breed is overrepresented with Copper Storage disease?
**- Bedlington terriers
- Doberman
- Dalmation
- Labs**
57
How is Copper storage disease diagnosed?
- **Biopsy required for definitive diagnosis**
- Rhodanine staining needed for copper
- **Copper quantification analysis** from biopsy
- Centrilobular copper indicates primary copper dz
- Periportal copper indicates secondary copper dz
58
What is the treatment protocol for patients with copper storage disease?
- **Penicillamine: Copper chelating drug of choice**
- Denamarin / SAMe + other neutraceuticals
- **Copper restricted diet lifelong**
(add GI protectants due to GI side effects from Penicillamine)
59
What is the most common cause of hepatobiliary disease in cats?
Hepatic lipidosis
60
List secondary causes of hepatic lipidosis in cats
- DM
- Pancreatitis
- GI disease
- Renal failure
- Neoplasia
- Inflammatory hepatobiliary disease
61
What is a primary cause of hepatic lipidosis in cats?
**Obese, anorexic cats**
(Primary is less common, secondary more common)
62
What is hepatic lipidosis?
- Accumulation of **excessive triglycerides** resulting in **impairment of liver function** and **intrahepatic cholestasis**
63
Why are cats more prone to hepatic lipidosis than dogs?
- **Cats are carnivores, dependent on lipid and protein metabolism**
64
What clinical signs can be seen in cats with hepatic lipidosis?
- CS typical of ACUTE liver failure
- V/D
- Hepatic encephalopathy
- Palpable hepatomegaly
- Jaundice
- Recent weight loss
- **Cervical ventroflexion**
65
What bloodwork findings are seen with hepatic lipidosis?
- **High ALP with normal GGT** if primary cause
- **High ALP with High GGT** if secondary cause
- **Hypokalemia and Hypophosphatemia (poor prognostic indicator)**
- Mild hypoalbuminemia
- +/- coagulopathies
66
How is hepatic lipidosis diagnosed?
- Definitive diagnosis made with biopsy but rarely necessary or recommended (cats usually really sick)
- Usually diagnosed on FNA/cytology **(only FNA liver AFTER giving Vitamin K)**
Note: Liver biopsy only recommended if failure to improve w treatment or if suspect underlying hepatic disease
67
What is the treatment protocol for cats with hepatic lipidosis?
- **Nutritional support is mainstay**, tube feeding if needed
- **High protein, low carb diet**
- **Increase feedings by 25-30% (at the max) per day to AVOID REFEEDING SYNDROME**
- **Monitor potassium and phosphorus**
(+ Antiemetics, prokinetics, hepatoprotectants, Vitamin K, Cobalamin)
68
What is the prognosis for cats with hepatic lipidosis?
- **Good if survives initial 96 hours** and rapidly treated
- Can take months for cats to eat, requires long term feeding tube
- **Hypokalemia and Hypophosphatemia are poor prognostic indicators**
69
What electrolyte abnormalities can be seen with hepatic lipidosis?
- **Hypokalemia and Hypophosphatemia**
**(poor prognostic indicators)**
70
How is hepatocutaneous syndrome diagnosed?
- Biopsy showing **Parakeratotic hyperkeratosis and classic red, white and blue appearance**
- **Swiss cheese or honeycomb appearance on liver ultrasound**
- Decreased plasma AA's (hard to test)
71
How is hepatocutaneous syndrome treated?
- AA supplementation
- Zinc + EFAs + egg yolks
- High protein diet
- Hepatoprotectants
- Treat skin lesions
**(Avoid corticosteroids / Prednisone.. risk of precipitating DM)
72
What is the prognosis for a patient diagnosed with hepatocutaneous syndrome?
Poor prognosis, 1-3 months
73
What is the most common cause of acquired PSS?
- **Secondary to chronic portal hypertension from hepatic fibrosis/cirrhosis**
74
How is an acquired PSS diagnosed?
Doppler ultrasound of liver showing decreased velocity of portal vein blood flow or hepatofugal (backward) blood flow
75
What test is most useful in differentiating between a PSS and microvascular dysplasia?
- **Protein C**
- **Normal Protein C with Microvascular dysplasia**
(SASx: protein C > 70% for MVD)
76
FNA of the liver is a good method in diagnosing which conditions?
- **Hepatic lipidosis**
- **Vacuolar hepatopathy**
- Round cell neoplasia
- Rarely Toxoplasma or Leishmania
(NOT used to diagnose chronic hepatitis or copper hepatopathy.. biopsy required)
77
What condition results in a **swiss cheese or honeycomb appearance on ultrasound of the liver**?
Hepatocutaneous syndrome
