Liver Intestine Flashcards
Indications for liver transplant include…
- End stage liver disease with signs and symptoms of hepatic decompensation, not controlled by alternative therapeutic measures
- All other alternative medical and surgical treatments have been exhausted
Indications for liver transplant include the following diseases…
- Chronic Hepatocellular Disease
- Chronic Cholestatic Disease
- Metabolic Liver Disease
- Hepatic Malignancy
- Acute/Fulminant Liver Failure
- Vascular Disease
Signs of hepatic decompensation include…
- esophageal /gastric variceal bleeding
- bleeding from portal hypertensive gastropathy
- hepatic encephalopathy
- spontaneous bacterial peritonitis
- ascites
- coagulopathy
- hepatocellular carcinoma
Chronic hepatocellular disease includes…
- Hepatitis C Cirrhosis (HCV)
- Hepatitis B Cirrhosis (HBV)
- Alcohol related Cirrhosis: Laennec’s Cirrhosis
- Autoimmune Hepatitis (AIH)
Chronic cholestatic liver disease includes…
- Primary Biliary Cholangitis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- Secondary Sclerosing Cholangitis
- Biliary Atresia
- Progressive Familial Intrahepatic Cholestatic (PFIC)
Metabolic liver disease includes…
- Nonalcoholic Steatohepatitis (NASH)
- Wilson’s Disease (acute or chronic)
- Alpha-1 Antitrypsin Deficiency
- Primary Hereditary Oxalosis
- Primary Hemochromatosis
Hepatic malignancies include…
- Hepatocellular Carcinoma
- Cholangiocarcinoma
- Hepatoblastoma
Acute liver failure can be caused by…
- Drug Toxicity
- Acetaminophen
- Antibiotics, Isoniazid (INH)
- Toxins
- Mushrooms (Amanita phalloides)
- Metabolic Wilson’s Disease
- Hepatitis
- Viral (Hepatitis B)
- Autoimmune
- Other Acute fatty liver of pregnancy
Vascular complications that may lead to referrals for liver transplant can include…
- Budd Chiari : Thrombosis of hepatic veins:
- Gradual leading to cirrhosis
- Rapid can result in acute liver failure
- Veno-occlusive Diseases:
- Small vein blockages
- Chemo or hereditary
Post liver transplant vascular complications can include…
- Portal vein thrombosis
- Hepatic artery thrombosis
Absolute contraindications to liver transplant include…
- Severe cardiac or pulmonary disease:
- Pulmonary hypertension
- Hepatocellular carcinoma with metastatic spread
- Uncontrolled sepsis
- Extrahepatic malignancy
- Ongoing alcohol or illicit substance abuse
Key issues to address in the diagnosis of liver disease include…
- The etiology of the liver disease
- Disease conditions that are important to know about prior to transplant that could affect the post-transplant recovery and outcomes
A complete history and physical is conducted to…
assess disease severity and prognosis, confirm diagnosis, and optimize management.
The goals of liver transplant evaluation are to…
determine if transplant is the best treatment and to determine if patient can undergo transplant safely
Laboratory Tests specific to liver evaluation include:
- Basic Laboratory
- Tests Liver function tests
- PT/ INR, PTT
- Markers for autoimmune liver disease
- Antinuclear antibody, anti mitochondrial antibody
- Ceruloplasmin
- Alcohol and drug levels
- Virology Screening: Hepatitis A, B, C; HIV; Cytomegalovirus IgG/IgM, Epstein-Barr Virus
- Cancer screening:
- Alpha-fetoprotein (afp)
- ca19-9
Alpha-fetoprotein (AFP) is…
a tumor marker for Hepatoblastoma (mainly seen in pediatrics) and hepatocellular carcinoma (mainly seen in adults)
Normal range is 10-20 ng/mL
CA19-9 is…
a tumor marker for cholangiocarcinoma and pancreatic cancer
Normal range is 0-37 units/mL
The normal range for BUN is…
7-20 mg/dL
The normal range for creatinine is…
0.6 - 1.2 mg/dL
The normal range for AST is…
10-40 units per liter
The normal range for ALT is…
7-45 units per liter
The normal range for GGT is…
9 - 48 units/liter (liver damage/damage to bile ducts)
The normal range for total bilirubin is…
0.3 - 1.2 milligrams per deciliter
The normal range for amylase is…
40-140 U/L
The normal range for lipase is…
0 - 160 U/L
The normal range for C-peptide is…
0.5 - 2 ng/mL (indicates high insulin production)
The normal range for Albumin is…
3.4 - 5.4 g/dL
The normal range for alkaline phosphatase is…
40 - 150 U/L (liver damage/gall bladder)
Specific testing for alcoholic cirrhosis should include…
- psychiatric evaluation
- individual treatment plan
Specific testing for primary sclerosing cholangitis should include…
- Endoscopic retrograde cholangiopancreatography (ERCP) with brushings (XRAY with scope- long flexible lighted tube)
- Rule out cholangiocarcinoma
Specific testing for primary biliary cholangitis should include…
- Bone densitometry
- rule out osteoporosis
Specific testing for Alpha-1 Antitrypsin Deficiency should include…
Pulmonary consult as lung can also be affected and they are at risk for emphysema
Specific testing for acetaminophen overdose should include…
- psychiatric evaluation
- rule out mental illness
Candidates may be assigned any of the following priority statuses based on OPTN requirements:
- Adult status 1A, Pediatric 1A and 1B
- Status 7 or Inactive
- Based on MELD score
- Based on PELD score
- MELD/PELD exception
MELD stands for…
model for end stage liver disease
An Adult Status 1A patient is…
- in ICU with life expectancy < 7days;
- Acute liver failure (<8 weeks)
- Hepatic Artery Thrombosis within 7 days of transplant
- Primary Graft Non-Function
- Acute decompensated Wilson’s disease
MELD scores typically range from…
6 to 40
A MELD score is comprised of…
- Creatinine, Bilirubin, INR and Sodium.
*Albumin and Sex (MELD 3.0) - Also need to include if the patient has received 24 hours of CVVHD or dialysis twice in the week
The higher the MELD score…
The sicker the patient
MELD recertification and labs are required on Status 1 adults…
Every 7 days; labs within 48 hours
MELD recertification and labs are required for adults with MELD > or = 25…
Every 7 days; labs within 48 hours
MELD recertification and labs are required for adults with MELD 18-24 …
Every 30 days; labs within 7 days
MELD recertification and labs are required for adults with MELD 11 - 17…
Every 90 days; labs within 14 days
MELD recertification and labs are required for adults with MELD < or = 10…
Every 12 months; labs within 30 days
If recertification is not completed on time…
The patient’s MELD score defaults to previous lower score for a period of time. if still not re-certified, the candidate will be assigned a MELD/PELD of 6.
Listing exceptions can be obtained when…
- Hepatopulmonary Syndrome
- PaO2<60 mmHg
- Portopulmonary syndrome
- MPAP>35mmHg
- Cholangiocarcinoma
- Need OPTN approved protocol
- Treatment plan
The PELD scoring system is used when…
- Candidates <12 years of age
- Pediatric candidates 12-17 years old use MELD, however they Maintain other priorities assigned to pediatric candidates
- Score range similar to adults
- Sicker patient has a higher score
Pediatric listing statuses include…
Status 1A; Status 1B, and Exceptions
The PELD score is comprised of…
Albumin, bilirubin, INR, Serum Creatine, and: Growth and Age if child <1 year
According to OPTN Policy 9.1.B, Pediatric Status 1A includes patients with…
- Fulminant Liver Failure
- Primary non-function within 7 days of transplant
- Hepatic artery thrombosis within 14 days
- Acute decompensated Wilson’s disease
According to OPTN Policy 9.1.C, Pediatric Status 1B patients include…
- Non-metastatic hepatoblastoma
- Metabolic
Exceptions for pediatric listing may be obtained…
- Primary hyperoxaluria (excessive urinary excretion of oxalate, which can lead to kidney stones)
- GFR <25, listed for kidney and liver transplant
- ALT greater than or equal to 2000
- INR greater than or equal to 2.0
- Total bilirubin greater than or equal to 10
Livers are first allocated to…
the most urgent liver transplant candidates (Status 1A and 1B) listed at transplant hospitals within a radius of 500 nautical miles of the donor hospital.
Following offers to the most urgent candidates, livers from adult donors will be offered to candidates…
at hospitals within distances of 150, 250 and 500 nautical miles of the donor hospital. These offers are grouped by medical urgency.
Management of listed liver patients requires…
- Collaborative care between transplant team members
- Communication with primary care physician
- Re-evaluation and adjustment of MELD or PELD score
- Screening for cancer (HCC), varices, cardiac and other complications
- Emotional support and education
- Management of medical complications
Medical complications of end stage liver disease can include…
- Hepatic Encephalopathy
- Ascites
- GI Bleeding or Esophageal Varices
- Spontaneous Bacterial Peritonitis
- Hepatorenal Syndrome
- Cholangitis
- Hyponatremia
- Thrombocytopenia
- Malnutrition
A Blakemore tube is used to…
- stop or slow bleeding from the esophagus and stomach:
- The bleeding caused by gastric or esophageal varices, which are veins that have swollen from obstructed blood flow.
- The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis.
- The gastric lumen is used to aspirate stomach contents.
- It is a temporary measure: ulceration and rupture of the esophagus and stomach are recognized.
- It is not used frequently
A TIPS procedure (Transjugular Intrahepatic Portosystemic shunt) is a…
stent placed into the hepatic vein
to reduce portal HTN and complications of variceal or GI bleeding
Bridge-to-transplant options for HCC patients include…
- Surgical resection
- Ethanol injection
- Radiofrequency ablation (RFA)
- Chemoembolization (TACE)
- Radioembolization (Y-90)
A Kasai procedure…
connects the liver directly to the small intestine to drain bile
Donor selection is based on…
- ABO compatibility
- Size compatibility
- Serologies
- Hepatic function
- Liver function tests
- Cardiac arrest & downtime, acidosis, pressors
- Medical History
- Obesity
- Age
- Atherosclerosis & presence of co-morbid conditions
- Social History
- ETOH use
A liver transplant operation typically takes…
6-10 hours
Liver transplant surgery is a complex procedure that includes…
- Hepatectomy
- Implantation:
- Venous outflow: Hepatic vein and portal vein
- Venous inflow: Portal vein
- Arterial anastomosis: Hepatic artery
- Reperfusion
- Biliary anastomosis
Two types of surgical biliary reconstruction options include…
- Duct-to-duct choledocholedochostomy
- Roux en Y choledochejunostomy
The preferred surgical biliary reconstruction method is…
duct to duct choledocholedochostomy
Early post-operative monitoring of liver transplant patients includes…
- ICU/LOS Management
- Graft Function
- Mental status
- Renal function: urine output, creatinine
- Hemodynamic status: pressors
- INR, ALT, AST, Bilirubin
- Doppler US: Assess hepatic artery and portal vein
- Broad spectrum antibiotics
- Immunosuppression
Early post-operative monitoring of liver transplant patients requires fluid management via…
- Use of albumin
- Use of loop diuretics I
- nitially patients are fluid overloaded
- Interstitial fluid mobilization
- POD 3 mobilize independently
Early post -operative monitoring of liver transplant patient requires monitoring of hematological issues including…
- Anemia
- Watch for signs of bleeding
- May need blood transfusion
- Thrombocytopenia (low platelets)
- Can be days or weeks to recover
- Vitamin K deficiency
Early post-operative complications can include…
- Primary Graft Non-Function
- Poor Early Graft Function
- Hepatic Artery Thrombosis
- Portal Vein Thrombosis
- Bile Leak
- Bleeding
Primary Graft Non-function is characterized by…
- Incidence: 2-5%
- Presentation
- Might be suspected in the OR
- Cardiovascular instability, severe coagulopathy
- Diagnosis
- Clinical presentation
- Liver biopsy
- Cause: Unknown
- Marginal donor (age, fatty liver), prolonged ischemic time
- Treatment
- Re-transplantation
- Status 1
Poor Early Graft function is characterized by…
- Presentation
- PT >20 sec
- Decrease glucose production, slow lactate clearance
- AST > 2,000 = severe injury, AST > 5,000 = very severe injury
- Diagnosis
- Clinical presentation
- Liver biopsy
- Cause: Ischemic, anoxic or re-perfusion injury
- Treatment
- Supportive care
- Prostaglandin E/Prostacycline
Hepatic Artery Thrombosis is characterized by…
- Incidence: 2-5%
- Presentation
- Rapid onset hepatic dysfunction
- Can be slow onset or biliary complication
- Diagnosis
- Clinical presentation
- Liver ultrasound and/or angiogram
- Cause
- Pediatric and technical variant graft at higher risk
- Technical problems
- Rejection - decreased vascular compliance & edema
- Treatment
- Attempt re-arterialization if possible
- Associated with higher incidence of biliary complication
- Re-transplantation; Status 1A if occurs within 7D for adult and 14D for pediatrics
Portal Vein Thrombosis is characterized by…
- Presentation
- Massive ascites
- Renal failure
- Hemodynamic collapse
- Diagnosis
- Clinical presentation
- Liver ultrasound with doppler
- Venogram
- Cause
- Technical
- Decreased portal flow
- Treatment
- Anticoagulation
- Revision of anastomosis
- Re-transplantation in some instances
Bile Leak is characterized by…
- Presentation
- Fever and/or sepsis
- Abdominal pain
- Jaundice, bilious drainage from incision/drains
- Diagnosis
- Clinical presentation
- Ultrasound, MRCP/ERCP, Interventional Radiology
- Cause
- Technical
- Prolonged ischemia
- Treatment: Surgical repair
Bleeding is characterized by…
- Presentation
- Obvious bleeding
- Decrease in hemoglobin and hematocrit on routine labs
- Diagnosis
- Hemoglobin and CVP measurements should be monitored
- Hemoglobin goal usually lower
- Cause
- Surgical complication
- Underlying coagulopathy
- Poorly functioning graft
- Treatment
- Radiology exploration (CT)
- Surgical exploration to determine source
- Blood products as indicated
Extravasation is another name for…
bile leak
Acute cellular rejection is characterized by…
- Presentation
- Increase in AST and ALT
- RUQ pain
- Fever
- Asymptomatic
- Diagnosis
- Liver ultrasound with doppler (r/o vascular etiology)
- Liver biopsy
- Treatment
- Steroid bolus
- Manipulation of maintenance immunosuppression
Chronic Liver rejection is characterized by…
- Presentation
- Increase in AST and ALT
- Increase in bilirubin and ggt
- Diagnosis
- Liver ultrasound with doppler (r/o vascular etiology)
- Liver biopsy
- Treatment
- Immunosuppression
- Tacrolimus, sirolimus, additional agent
- May result in need for re-transplant
Biliary stricture is characterized by…
- Presentation
- Jaundice, icterus, increase in AST/ALT, RUQ pain.
- Usually ischemic in origin
- Associated with late HAT
- Occurs most commonly at the anastomosis site
- Diagnosis
- Liver ultrasound with doppler MRCP for more specific imaging
- Treatment
- Dilatation + stent placement
- Surgical reconstruction of biliary anastomosis
- Convert duct-to-duct to a Roux-en-Y anastomosis
Liver patients should be monitored for the following post-transplant infections…
- Cytomegalovirus (CMV)
- Epstein Bar Virus (EBV)
- Post Transplant Lymphoproliferative Disease (PTLD)
- Herpes Simplex Virus (HSV)
- Pneumocystis carinii pneumonia (PCP)
- Fungal Infections (Thrush)
Liver patients should be monitored for the following post-transplant recurrent diseases…
- Hepatitis B (HBV)
- Hepatitis C (HCV)
- Autoimmune Hepatitis (AIH)
- Primary Biliary Cholangitis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- Alcoholic Cirrhosis (ETOH)
- Hepatocellular Carcinoma (HCC)
Indications for intestinal transplant include…
- Severe short bowel (AKA: short gut syndrome)
- Massive resection; necrotizing enterocolitis, tumors
- Dysmotility disorders: Hirschsprung’s disease
- Ischemia
- Chron’s disease
- Trauma
- Gastroschisis
- Pseudo-obstruction
- Volvulus
Absolute contraindications to intestine transplant include…
- Systemic uncontrolled malignancy
- Metastatic disease
- Overwhelming sepsis
- Positive blood culture: ex. Klebsiella
- Cardiopulmonary insufficiency
Key factors that would be important to obtain in medical history for intestinal transplant include…
- Previous abdominal surgeries
- adhesions from prior surgeries
- h/o intra-abdominal infection
- congenital anomalies or portal HTN
Lab values specific to intestinal transplant would include…
- albumin
- pre-albumin
- transferrin
Diagnostics tests specific to intestinal transplant would include…
- UGI with small bowel series
- GI Motility studies
- Colonoscopy
- Abdominal US
Pre-transplant education of an intestine transplant should include information…
That there may be a need for a temporary ileostomy and feeding tube
Intestine patients are list per OPTN policy as…
- Status I: require transplant in the near future due to permanent intestinal failure, poor venous access and liver dysfunction
- Status II: permanent intestinal failure but stable liver function and venous access
The 3 types of intestinal transplants include…
- Isolated intestine
- Combined intestine & liver
- Multivisceral: combinations of intestine, liver, stomach and/or pancreas
Intestinal surgery can take…
8-12 hours
Post intestinal transplant complications may include…
- Surgical
- Biliary reconstruction
- Vascular and gastrointestinal anastomoses
- Hemorrhage
- Gastrointestinal bleeding
- Hypermotility
- Wound dehiscence
- Small bowel perforation
Assessment of the graft function includes…
- Observe for abdominal distention and signs of pain
- Auscultate for bowel sounds
- Palpate to assess for firmness or abdominal rigidity
- Assess stoma output for changes in:
- Volume: trend or acute increase
- Color: from yellowish brown to melena or frank blood
- Consistency: increased watery fluid
Normal stomal output for adults who have undergone intestinal transplant is…
1-2 L/day
Normal stomal output for children who have undergone intestinal transplant is…
40-60 ml/kg/day
The most common viral infection to monitor for in intestinal transplant patients is…
CMV
Acute rejection for intestinal transplant is characterized by…
- Clinical presentation
- Change in stool output (increase, watery), fever, abdominal pain or distention, nausea and vomiting
- Endoscopic appearance of the graft
- Surveillance endoscopies via the ileostomy are usually performed 2x/week for the first 4-6 weeks following transplant
- Histologic findings
- BIOPSY EVALUATION IS THE GOLD STANDARD
