Liver/Intestine Transplant Flashcards
What are the signs of hepatic decompensation?
7 items
- esophageal/gastric variceal bleeding
- bleeding from portal hypertensive gastropathy
- hepatic encephalopathy
- spontaneous bacterial peritonitis
- ascites
- coagulopathy
- hepatocellular carcinoma
Indicates for liver transplant include end stage liver disease with signs of what?
Hepatic decompensation
What disease categories are indications for liver transplant?
6 items
- Chronic hepatocellular disease
- Chronic cholestatic disease
- Metabolic liver disease
- Hepatic malignancy
- Acute/Fulminant liver failuire
- Vascular disease
Chronic hepatocellular disease includes what diseases?
4 items
- Hepatitis C (HCV)
- Hepatitis B (HBV)
- Alcoholic Cirrhosis
- Autoimmune Hepatitis (AIH)
Laennec’s Cirrhosis is a type of cirrhosis of the liver associated with alcoholism.
Chronic cholestatic liver disease includes what diseases?
5 items
- Primary Biliary Cirrhosis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- Secondary Sclerosing Cholangitis
- Biliary Atresia
- Progressive Familial Intrahepatic Cholestasis (PFIC)
Metabolic liver disease includes what diseases?
5 items
- Nonalcoholic Steatohepatitis (NASH)
- Wilson’s Disease (acute or chronic)
- Alpha-1 Antitrypsin Deficiency (A1AT)
- Primary Hereditary Oxalosis
- Primary Hemochromatosis
What are the types of Hepatic Malignancies?
3 items
- Hepatocellular carcinoma
- Cholangiocarcinoma
- Hepatoblastoma
Acute liver failure can be caused by drug toxicity. What are the 2 most common drugs?
Acetaminophen, Antibiotics
Acute liver failure can be caused by what Metabolic Disease?
1. NASH
2. Wilson’s Disease
3. A1AT
4. Primary Hemochromatosis
2
Acute Liver Failure can be caused most commonly by what 2 viral processes?
Viral Hepatitis B
Autoimmune Hepatitis
When does fatty liver cause acute liver failure?
During pregnancy
What 2 vascular complications may cause the need for transplant?
Liver
Budd Chiari
Veno-occusive diseases
Budd Chiari = thrombosis of hepatic veins. Gradually leads to cirrhosis. It can lead to acute liver failure if progression is rapid.
AFP is a tumor marker for what hepatic malignancy typically seen in kids?
AFP is a tumor marker for what hepatic malignancy typically seen in adults?
Hepatoblastoma
Hepatocellular carcinoma
Normal range is 10-20 ng/mL
CA 19-9 is a tumor marker for what 2 malignancies?
Cholangiocarcinoma and pancreatic cancer
Normal range is 0-37 units/mL
What do low levels of c-peptide indicate? What about high levels?
Low C-peptide levels: May indicate type 1 diabetes, insulin resistance, or pancreatic damage.
High C-peptide levels: May indicate type 2 diabetes, an insulin-producing tumor, or a medication that stimulates insulin production.
Normal levels are 0.5 - 2 ng/mL
What hepatic malignancy should be ruled out with Primary Sclerosing Cholangitis (PSC)?
Cholangiocarcinoma
What specific testing should be completed for Primary Biliary Cirrhosis and why?
Bone densitometry
To rule out osteoporosis
What lung complication are Alpha-1 Antitrypsin patients at risk for?
Emphysema
What is the purpose of a Blakemore tube?
To stop or slow bleeding from the esophagus and stomach
What is the maximum time a Blakemore tube esaphageal tube should remain inflated?
1. 1 hour
2. 6 hours
3. 12 hours
4. 24 hours
2
This is done to avoid necrosis.
What is the purpose of the gastric lumen of the Blakemore tube?
Aspirate stomach contents
What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS) and why is it done?
A stent placed in the liver to reduce portal HTN
What is a Kasai Procedure and why is it done?
A procedure to connect the liver directly to the small intestine to drain bile.
What is the average time it takes for a liver transplant?
6-10 hours
What are the 4 main steps of a liver transplantation?
- Hepatectomy
- Implantation
- Reperfusion
- Biliary anastomosis
Implantation involves anastomosis of the hepatic vein, portal vein, and hepatic artery.
What type of surgical biliary reconstruction is shown here?
Duct-to-duct choledocholedochostomy
This is the preferred method of surgical biliary reconstruction.
What type of surgical biliary reconstruction is shown here?
Roux en Y choledochejunostomy
How soon can Primary Graft Non-Function be suspected?
In the OR
What is the treatment for Primary Graft Non-Function?
Status 1 listing and retransplant
What would you see in the following that would indicate Poor Early Graft Function?
- PT
- AST
- Glucose production
- Lactate clearance
PT>20 sec
AST>2000 = severe injury; >5000 = very severe injury
Decreased glucose production
Slow lactate clearance
What are the causes of Poor Early Graft Function?
Ischemia injury
Anoxic injury
Re-Perfusion Injury
What is the treatment for Poor Early Graft Function?
Liver
Prostaglandin
What is the main sign of Hepatic Artery Thrombosis?
Hepatic dysfunction
How is a Hepatic Artery Thrombosis Diagnosed?
Ultrasound or Angiogram
How is rejection related to Hepatic Artery Thrombosis?
Rejection causes decreased vascular compliance and edema.
How are biliary complications related to Hepatic Artery Thrombosis?
Hepatic Artery Thrombosis is associated with higher incidence of biliary complication.
What are 3 signs of a Portal Vein Thrombosis?
- Massive ascites
- Renal failure
- Hemodynamic collapse
How is Portal Vein Thrombosis Diagnosed?
Liver ultrasound with doppler
Venogram
What is the treatment for Portal Vein Thrombosis post transplant?
- Anticoagulation
- Revision of anastomosis
- Retransplant in some cases
What are the signs of a bile leak?
3 items
- Fever
- Abdominal pain
- Jaundice, incisional bilious drainage
How is a bile leak diagnosed?
- Ultrasound
- MRCP/ERCP
What is the treatment for a bile leak?
Surgical repair
What are the signs of acute cellular rejection in liver transplant patients?
3 items
- Increase in AST/ALT
- RUQ pain
- Fever
May also be asymptomatic
What are the signs of biliary strictures?
- Jaundice
- Increase in AST/ALT
- RUQ pain
Where do biliary strictures most common occur?
The anastomosis site
What are 3 possible treatments for a biliary stricture post liver transplant?
- Dilatation + stent placement
- Surgical reconstruction of biliary anastomosis
- Convert duct-to-duct to Roux-en-Y anastomosis
Post-liver transplant patients should be monitored for which infections?
6 items
- Cytomegalovirus (CMV)
- Epstein Barr Virus (EBV)
- Post Transplant Lymphoproliferative Disease (PTLD)
- Herpes Simplex Virus (HSV)
- Pneumocystis carinii pneumonia (PCP)
- Fungal Infections (Thrush)
What are indications for intestinal transplant?
8 items
- Short gut syndrome
- Resection, necrotizing enterocolotis
- Tumors
- Hirschprung’s Disease
- Chron’s Disease
- Gastroschisis
- Pseudo-obstruction
- Volvulus
Intestinal transplant surgery takes how long on average?
8-12 hours
What should you assess for changes in the stoma output of an intestinal transplant patient?
- Volume: acute increase
- Color: melena or frank blood
- Consistency: increased watery fluid
What is the normal stool output volume for adults post-intestine transplant?
1-2 L/day
What is the normal stool output volume for children post-intestine transplant?
40-60 mL/kg/day
What is the most common viral infection to monitor for in intestinal transplant?
CMV
