Exam II Liver Biliary Disease

Question 1

Alanine transaminase (ALT).Liver enzyme for ____ breakdown. Elevated with ____ damage.
___ to ____ U/L

Answer 1

protein
liver
7 to 55 U/L

Question 2

Aspartate transaminase (AST).Liver enzyme, metabolizes _____ ____. Increased levels may indicate liver damage, disease or _____ damage.
___ to ___ U/L

Answer 2

amino acids
muscle
8 to 48 U/L

Question 3

Alkaline phosphatase (ALP).Liver (and bone) enzyme for protein breakdown. Increased levels may indicate liver damage or disease, blocked ____ ____ or ____ disease.
___ to ___ U/L

Answer 3

bile duct or bone
40 to 129 U/L

Question 4

Albumin and total protein._____ synthesized in the ____. Decreased levels may indicate liver damage or disease.
Albumin:___ to ___ g/dL
Total protein:____ to ____ g/dL

Answer 4

protein
liver
3.5 to 5.0 g/dL
6.3 to 7.9 g/dL

Question 5

Bilirubin.Produced during the normal breakdown of ____, passes through the liver, excreted in _____. Elevated bilirubin/jaundice might indicate liver damage, disease or certain types of anemia.
0.1 to ___ mg/dL (3 mg/dL leads to ____ jaundice; >4 mg/dL leads to ____ jaundice)

Answer 5

RBCs
stool
1.2 mg/dL
scleral
generalized

Question 6

Gamma-glutamyltransferase (GGT). Liver enzyme. Increased levels may indicate ___ or ___ ___ damage.
__ to __ U/L

Answer 6

liver or bile duct
8 to 61 U/L

Question 7

_-______ _____ (__).Liver enzyme. Elevated levels may indicate liver damage but can be elevated in many other disorders.
___ to 222 U/L

Answer 7

L-lactate dehydrogenase (LD)
122

Question 8

Prothrombin time (PT).Increased PT may indicate ____ damage but can also be elevated with _____.
___ to ___ seconds

Answer 8

liver
anticoagulants
9.4 to 12.5 seconds

Question 9

International normalized ratio (INR). Prolonged correlates with impaired ____function, impaired non-specific _____ and reliably predicts liver disease ____.
≤ ___

Answer 9

liver
coagulation
survival
1.1

Question 10

Benign postoperative intrahepatic cholestasis: usually after ____ procedure, increased incidence with ____, ____, ____.

Answer 10

long
hypotension, hypoxia, transfusion

Question 11

Benign postoperative intrahepatic cholestasis: symptoms - ____ with increased ____, other labs normal

Answer 11

jaundice
bili

Question 12

Benign postoperative intrahepatic cholestasis: usually resolves when ____ _____ improves

Answer 12

underlying condition

Question 13

OTHER CAUSES OF POST-OP HEPATIC DYSFUNCTION/JAUNDICE (5)

Answer 13

• hematoma, hemolysis, sepsis
• drug-induced
• autoimmune

Question 14

Acute cholecystitis: obstructed ____ duct or ____ ____ duct leading to painful inflammation

Answer 14

cystic
common bile duct

Question 15

Acute cholecystitis symptoms (3):

Answer 15

• N/V
• fever
• RUQ pain that may radiate to the back

Question 16

Acute cholecystitis treatment: ____, _____, _____, or ______

Answer 16

IVF, opioids, cholecystectomy (usually lap), or ERCP

Question 17

Acute cholecystitis: trendelenburg + insufflation = increased _____ pressure which leads to decreased _____ and decreased ___ ____

Answer 17

abdominal
ventilation
venous return

Question 18

Acute cholecystitis: opioids may cause ___ of ____ ____

Answer 18

sphincter of Oddi spasm

Question 19

Hepatitis:
Viral: A (50%), B (35%), C (15%), D (only seen with Hep B), HSV, CMV, Epstein-Barr
Tx: _____
Prevention: Precautions (avoid ____, get _____)

Answer 19

symptomatic
exposure
vaccines

Question 20

Hepatitis:
Drug Induced: ____ or dose-related
Common: ______ OD leads to toxicity and necrosis
Tx: Conjugate within 8 hours with _____

Answer 20

idiosyncratic
acetaminophen
N-acetylcysteine

Question 21

Hepatitis:
Autoimmune: No ____ treatment. Can progress to failure with need for _____.
Tx: ______ for remission

Answer 21

curative
transplant
corticosteroids

Question 22

Hepatitis:
Halothane: Form of autoimmune hepatitis after exposure. May cross-sensitize to other agents EXCEPT _____ (d/t to its different metabolites).

Answer 22

sevoflurane

Question 23

Hepatitis:
Chronic: ___months, usually d/t _____, progresses to cirrhosis/multi-organ dysfunction

Answer 23

> 6 months
ETOH

Question 24

Cirrhosis:
Parenchymal liver damage with regeneration leads to ____

Answer 24

nodules

Question 25

Cirrhosis symptoms: F____, m____, j____, a_____, g_____, testicular ____, ascites

Answer 25

Fatigue, malaise, jaundice, angiectasis, gynecomastia, testicular atrophy, ascites

Question 26

Cirrhosis: increased b____, LFTs, INR, t______, h_____, decreased a_____

Answer 26

increased bilirubin, LFTs, INR, thrombocytopenia, hypoglycemia, decreased albumin

Question 27

Cirrhosis: fibrosis leads to increased resistance, which causes ____ _____, ascites, ____megaly, ____megaly, peripheral edema

Answer 27

portal HTN hepato spleno

Question 28

Cirrhosis: Ascites Tx: A____, low ____ diet, diuresis, p______, portosystemic shunt Bacterial peritonitis d/t ascites has high ____&_____

Answer 28

albumin sodium paracentesis M&M

Question 29

Cirrhosis: Portal HTN leads to ____ ____ dilatation with potential heavy bleeding. May require intubation for airway protection and aspiration prevention. Tx: B____, s_____, β blockers, shunt (____ vein to ____ vein)

Answer 29

esophageal venous banding sclerotherapy hepatic portal

Question 30

Hepatic Encephalopathy Failing liver causes ____ changes Shunts can worsen (____/____ bypass hepatic clearance) Tx: Low protein, drugs to ↓ ammonia absorption; avoid o____, s____, a_____

Answer 30

psych ammonia/metabolites opioids, sedatives, anesthetics

Question 31

Hyperdynamic Circulation ↓ ____ with ↑ _____ Cirrhosis can lead to ______ that is difficult to manage intraoperatively.

Answer 31

SVR CO cardiomyopathy

Question 32

Hepatopulmonary Syndrome Approx. ___% of cirrhosis patients Caused by intrapulmonary shunting, V/Q mismatch with dyspnea and hypoxia (worsens when ____) Tx: _____

Answer 32

25% upright transplant

Question 33

Portopulmonary Hypertension (____ ____ HTN + ____ ____ HTN) <4% of cirrhosis patients but high ____ with _____ life expectancy Tx: Prostaglandins, NO. Transplant - but only if PAP <___ mmHg

Answer 33

portal vein pulmonary artery mortality short 45

Question 34

Hepatorenal Syndrome (liver dz + renal failure) Exact etiology unknown but probably d/t ↓ ____ and _____ Type 1 (acute) or Type 2 (chronic) – dependent on speed of onset/severity of ____ function changes Tx: ____ ____ therapy, liver transplant

Answer 34

RBF dehydration renal renal replacement

Question 35

Coagulopathy Most coag factors and anticoagulant proteins synthesized by liver; liver clears ____ ____ factors. Coag function must be determined _____.

Answer 35

activated coag preoperatively

Question 36

Acute Liver Failure: 80-90% loss of liver function occurring in ___ ____ from appearance of 1st symptoms

Answer 36

< 4 weeks

Question 37

Fulminant liver failure: Failure within ___ ____ of 1st symptoms

Answer 37

8 days

Question 38

Acute Liver Failure: Mild encephalopathy causes _____ edema which leads to increased ___ and eventually ____ with high mortality

Answer 38

cerebral ICP coma

Question 39

Acute Liver Failure causes: _____ OD, ____ reaction, hepatitis, acute ____ liver of pregnancy, _____ dz, _____ syndrome

Answer 39

acetaminophen drug fatty Wilson's Reye's

Question 40

Acute Liver Failure Tx: Management of coagulopathies, renal failure, respiratory complications, metabolic abnormalities Newer intervention: “___ ___”, Caution: ____ monitoring with coagulopathy

Answer 40

liver dialysis ICP

Question 41

Acute Liver Failure: Without transplant, ___ ___. After transplant, ___ ___.

Answer 41

85% die 65% die

Question 42

____ of liver damage + type of _____ = perioperative risk

Answer 42

degree surgery

Question 43

____-____ score for severity classification (5 variables. See Table 17.6, p. 354.)

Answer 43

Child-Pugh

Question 44

Nutrition/Metabolic Pts are m______, v____ deficient, ↓ albumin, hypo_____, hyponatremia (with ↑ total body Na+), have altered drug metabolism.

Answer 44

malnourished vitamin hypoglycemic

Question 45

Encephalopathy May or may not be relational to ____ damage Investigate new onset ____ symptoms. Preoperative encephalopathy = ↑ ____ & _____ risks

Answer 45

liver neuro surgical & anesthesia

Question 46

Pulmonary Hepatopulmonary Syndrome? Portopulmonary HTN? Aspiration risk? Room air saturation? PFTs? PAP? _____ = full stomach/delayed emptying with need for RSI

Answer 46

Ascites

Question 47

Renal Hepatorenal syndrome Beware of ↑ _____/↓ clearance and metabolic _____ B____, hypo____, nephrotoxic drugs increase risk

Answer 47

creatinine acidosis bleeding, hypotension

Question 48

Circulation ↓ ____ partially compensated with ↑ ____. ↓ ____ causes interstitial edema

Answer 48

SVR CO albumin

Question 49

Consider ___ ___, foley, pressors. _____, ____, and ____ common for transplants.

Answer 49

art line phenylephrine, norepi, and vasopressin

Question 50

Coagulopathy Thromboelastography (TEG®, ROTEM®) may be useful. Consider vitamin ____ with _____.

Answer 50

K malnutrition

Question 51

Coagulopathy Consider targeted ___, _____, ____ transfusions. Citrate may not be metabolized. May need ____ treatment.

Answer 51

FFP, cryoprecipitate, platelets Ca++

Question 52

Drug Metabolism Affected by impaired liver metabolism, ↑ ___, ↓ ____ binding, ↓ ____. Consider ______ class (metabolized without liver enzymes).

Answer 52

Vd protein clearance benzylisoquinoline

Question 53

Postoperative Most common cause of cirrhosis patient death: ___ ___ To ICU immediately post-op

Answer 53

liver failure

Question 54

liver transplant >6,700 in U.S./year; >12,000 waiting; >56,000 in U.S. with transplanted liver Most common disease: ____ ____

Answer 54

hepatitis C

Question 55

liver transplant >90% are _____

Answer 55

cadaveric

Question 56

liver transplant Peds: Lobe of liver has _____ results Adults: Size-mismatching (small for size syndrome) is _____.

Answer 56

excellent problematic

Question 57

liver transplant Best results: Donor liver at least as ____ as native liver

Answer 57

large

Question 58

liver transplant Former contraindications: A_____, chronic hepatitis (especially ___) and ____. Now most frequent indications.

Answer 58

alcoholism C cancer

Question 59

liver transplant Model End-Stage Liver Disease (MELD) scores predict mortality probability within ___ ____ with ____ ____. MELD scores determine waiting list rankings.

Answer 59

90 days NO transplant

Question 60

liver transplant For ___ ___, Milan staging criteria used.

Answer 60

liver cancer

Question 61

transplant procedure 3 stages

Answer 61

1 dissection 2 anhepatic 3 reperfusion

Question 62

phase 1 dissection - Immobilizing vascular structures and native liver removal leading to _____ with ______ instability

Answer 62

hemorrhage hemodynamic

Question 63

phase 2 Anhepatic – Hepatic artery and portal vein clamped; venovenous bypass used. Retractors cause decreased _____/_____. No liver function leads to ____ _____, ↓ drug metabolism, ____ toxicity. Ca++ often needed.

Answer 63

ventilation/oxygenation metabolic acidosis citrate

Question 64

phase 3 - Reperfusion (neohepatic) – After anastomosis of donor liver. Vascular _____ (reperfusion) leads to CV instability, d_____, b_____, hypo_____, hyper______ (highest risk phase).

Answer 64

unclamping dysrhythmias bradycardia hypotension hyperkalemia

Question 65

Drug metabolism resumes after ______.

Answer 65

reperfusion

Question 66

Coag factors given to normalize clotting. With good perfusion, ____ improve, _____ ____ reverses, oxygenation improves. (Reperfusion/Neohepatic)

Answer 66

LFTs hyperdynamic circulation

Question 67

___-_____ now being done in some transplant centers.

Answer 67

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