5. gastrointestinal and hepatic ds.

Question 1

what is the livers dual blood supply

Answer 1

20% hepatic artery - oxygented blood
80% portal vein - nutrients

Question 2

function of hepatocytes

Answer 2

• synthesize proteins
• synthesize bilirubin
• produces bile and cholesterol
• regulate nutrients
• prepares drugs for excretion
• responsible for drug conjugation and metabolism

Question 3

what is phase I and phase II

Answer 3

phase I - cytochrome p450; can produce toxic metabolites

phase II - conjugation (glucuronidation, sulfation, inactivation by glutathione, etc)

Question 4

signs of liver ds

Answer 4

jaundice
ascites
edema
gi bleed
dark urine
light stool
mental confusion

xanthelasma

spider angiomas

palmar erythema

asterixis

hyperpigmentation

Question 5

symptoms of liver ds

Answer 5

appetite loss

bloating

nausea

RUQ pain

fatigue

mental confusion

Question 6

what is this

Answer 6

xanthelasma

signs of liver ds. due to cholesterold deposits in the dermis

Question 7

what is this

Answer 7

spider angioma

sign of liver ds but not specific for liver ds

due to loss of clotting factors

Question 8

what is asterixis

Answer 8

aka a flapping tremor

classic sign of hepatic encephalopathy (HE)

jerky movements when hands are extended at wrists

Question 9

HE

Answer 9

hepatic encephalopathy

• syndrome of altered neurologic function relayed to dysregulation of metabolism seen exclusively in pts with severe liver ds.

chronic for pts with cirrhosis

rarely fatal but big cause of hospitalizations of pts with cirrhosis

Question 10

blood tests for liver ds

Answer 10

most common CBC and CMP

complete blood count (CBC) and comprehensive metabolic panel (CMP)

Question 11

CBC evaluates what

Answer 11

RBC, WBC and platelets (PLTs)

Question 12

CMP evaluates what

Answer 12

chemical lscreen or SMAC 14 (sequential multiple analysis - computer)

consist of 14 blood tests that serves as a broad screening tool.

Question 13

liver function tess

Answer 13

• bilirubin
• ALP = alkaline phosphatase
• Transaminases
  
  • AST or SGOT asparate amino transferase
  • ALT or SGPT alanin amino transferase
  • GGT gama-glutamyl transferase
• Albumin
• Globulin

need to knw the abbreviations

Question 14

increase bilirubin

Answer 14

increased severity of liver injury

increased unconjugated serum (indirect) is NOT indicative of liver ds

increased conjugated (direct) IS indicative of liver ds

Question 15

if alkaline phosphatase is high

Answer 15

may indicate a cholestatic ds

not specific for liver ds though

altered in myriad of ds especially bone neoplasms (normal and neoplastic bone)

Question 16

ast high

Answer 16

aspartate aminotransferase SGOT

realted to glutamin oxalate metabolic pathways

indicates damage to the hepatocytes from hepatocellular ds

Question 17

alt high

Answer 17

alanine aminotransferase SGPT

part of pyruvate pathway in cell metabolism

indicates damage to the hepatocytes from hepatocellular ds

Question 18

ggt high

Answer 18

need for prot synth

used to detect alchol induced liver cell injury

indicates damage to the hepatocytes from hepatocellular ds

Question 19

ast:alt ratio

Answer 19

aspartate aminotransferase: alanine aminotransferase

ratio is more informative

lower the ratio, the most specific indicator of hepatic ds

Question 20

if albumin is low

Answer 20

hypoalbuminemia

not specific to liver ds

but indicative of chronic liver ds

Question 21

hepatitis b

Answer 21

• enveloped DNA virus while all the others are RNA viruses
• serum hepatitis, blood borne.
• chronicity 90% in infants, 25-50% in children and less than 5% in adults.

Question 22

hepatitis C

Answer 22

• RNA virus. No vaccine.
• higher risk for baby boomers
• theres a high risk for becoming chronic 75 to 85%

Question 23

mavyret

epclusa

harvoni

are used for what

Answer 23

mavyret (glecaprevir/pibrentasvir)

epclusa (sofosbuvir/velpatasvir)

harvoni (ledipasvir/sofosbuvir)

for hep C protease inhibitor therapy

Question 24

hepatitis D

Answer 24

• coinfectin with HBV
• more severe than HBV alone
• higher risk of fulminant hepatitis with massive hepatocellular destruction

Question 25

hepatitis A and E

Answer 25

infectious, fecal-oral v contagious and transmissible AIR BORNE not bood like the others vaccinations

Question 26

viral hepatitis dental considerations

Answer 26

* pt with active hep acute or chronic * defer all elective dental tc * if emergenct, consider referral, consult physician, isolation may be necessary

Question 27

viral hepatitis oral manifestations

Answer 27

bleeding mucosal jaundice glossitis angular cheilosis extrahepatic immunologic disorders with chronic HCV with oral lichen planus and sjogren like syndrome

Question 28

alcoholic liver ds dental considerations

Answer 28

- pts with suspected, active, untx alcoholic liver are not candidates for routine, elective dental tx - oral neglect is common, should pts should demondstate ability to care for their dentition before any signifcant tx is provided

Question 29

AST: ALT ratio for alcholic liver ds

Answer 29

greater than 2 different than the generic rule that low ratio means liver ds. ggt is also elevated.

Question 30

alcoholic liver ds oral manifestations

Answer 30

* neglect * bleeding * ecchymoses * petechiae * glossitis * angular cheilosis * alcohol odor * partoid enlargment * xerostomia * pt with jaudiced mucosal tissue and breath that is **sweet and musty** are associated with liver failure * alcohol abuse is a strong risk factor for oral squamous cell carcinoma.

Question 31

peri/intra oral dental tx considertions in liver ds

Answer 31

* perform extractions as atraumatically as possible * if doin SRP, do one tooth at a time not a whole quadrant * have local hemostatic agents available * place sutues in all extraction sites

Question 32

post dental tx considerations in liver ds

Answer 32

* have pt sit for 20 mins to make sure local hemostatis is adequate before sending them home * do not rx NSAIDs for pain management * Can give acetamniphen up to 2g daily * supply pt with gauze *

Question 33

is antibiotic prophylaxis needed for pts with liver ds

Answer 33

- NOT needed prior if no oral infection is present - pt with SEVER LIVER DS may need ab prophylaxis for invasive/surgical procuedures. Weigh out risk and benefits.

Question 34

LA to avoid for liver ds pts bc metabolized by the liver

Answer 34

* lidocaine * mepivacaine * prilocaine * bupivacaine *

Question 35

analgesics to avoid for liver ds pts bc metabolized by the liver

Answer 35

aspirin (*anticoagulant in nature and pt already has bleeding probs, need to coagulate)* acetaminophen (tylenol, datril) - can be used but limited. max daily dose 3-4 g. codeine meperidiene ibuprofen (motrin) hydrocodone, oxycodone

Question 36

sedatives to avoid for liver ds pts bc metabolized by the liver

Answer 36

diazepam barbiturates

Question 37

antibiotics to avoid for liver ds pts bc metabolized by the liver

Answer 37

ampicillin tetracycline metronidazole vancomycin

Question 39

if need a sedative for a liver ds pt what would you use

Answer 39

lorazepam - bc its half life is so short that it would not last a long time in the system