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Hepatic Biliary Systems exam 3 Flashcards

mordecai (71 cards)

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1
Q

What is cholelithiasis?

A

Gall stones. Hepatocytes secrete bile through bile ducts, into common hepatic duct, into gall bladder and common bile duct

Risk factors: fat pregnant female

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2
Q

Liver functions

Liver synthesizes glucose via _____.

Stores excess glucose as _____.

Synthesizes cholesterol and proteins into ____ and ____.

A

glucogenesis

glycogen

hormones and vitamins

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3
Q

Liver functions

Liver metabolizes fats, proteins and carbs to gerenate _____

Liver metabolizes drugs via ____ and other enzyme pathways

Liver _____ blood

A

energy

CYP 450

detoxifies

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4
Q

Liver functions

Liver is involved in the acute phase of ____ _____

Liver processes Hgb and stores ____

A

immune support.

iron.

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5
Q

Liver synthesizes all coag factors except 4. What are they?

Liver aids in volume control as a ___ _____

A

3, 4, 8( vWF)

blood reservoir

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6
Q

Liver has 8 segments. R and L lobes are separated by ____ ligament.

Where do the 3 hepatic veins empty?

A

Falciform (R lobe is bigger)

Right, middle and left hepatic veins empty into IVC!

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7
Q

Bile duct travels along ____ _____

Where does bile drain into?

How does bile enter duodenum

A

portal veins.

  • Bile drains through the hepatic duct into gall bladder & common bile duct
  • Bile enters duodenum via Ampulla of Vater
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8
Q

Describe O2 delivery in liver

A
  • 50% via Portal vein (deoxygenated)
  • 50% via Hepatic artery
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9
Q

What does portal vein arise from? How much hepatic blood flow does it supply?

Portal vein blood is deoxygenated blood from what 3 structures

A

portal vein arises from the splenic vein and superior mesenteric vein;makes up 75% HBF
* Portal vein blood is deoxygenated from GI organs, pancreas & spleen

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10
Q

What are 3 groups of hepatobiliary disease?

A

-hepatocellular injury (high AST/ALT)
-reduced synthetic function (low albumin, high PT/INR)
-cholestasis: high Alk phosphatase, low GGT, high bilirubin

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11
Q

What is choledocolithiasis?

Symtpoms?

A

-stone obsructing common bile duct–> biliary colic

initial: N/V, cramps, RUQ pain. Cholangitis sx: fever, rigors, jaundice

Tx: stone removal via ercp

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12
Q

What is ERCP?

What complication may happen?

A

-Endoscopics threads guidewire through sphincter of Oddi, into ampulla of vater to retrieve stone from pancreatic duct or common bile duct.
Positioning: prone w L tilt.
*May require glucagon for Oddi spasm!

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13
Q

What is primary biliary cholangitis aka biliary cirrhosis?

Tx?

women>

A

Autoimmune destruction of bile ducts with periportal inflammation and cholestasis. Leads to liver scarring, fibrosis, cirrosis.

No cure but exogenous bile acids slow progression

intrahepatic ducts only

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14
Q

Labs for Primary Biliary Cholangitis?

Liver biopsy reveals what?

A

Elevated Alk Phos, GGT and + antimitochontrial antibodies

Liver biopsy reveals bile duct destruction and infiltrations w lymphocytes

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15
Q

What is Wilson’s disease?

S/S?

AKA hepatolenticular degradation

A

-Autosomal recessive disease–> impaired copper metabolism.
-Excessive copper leads to oxidative stress in live, basal ganglia and cornea

S/S asymptomatic to sudden onset liver failure along w neurologic and psych manifestations

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16
Q

How is Wilson’s Disease diagnosed

A

serum ceruloplasmin, aminotransferases, urine copper level, liver biopsy (for Cu level)

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17
Q

What is the treatment of Wilson’s Disease

A

Treatment: copper chelation therapy and oral zinc to bind copper in GI

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18
Q

What is alpha-1 antitrpsin deficiency?
How is it diagnosed?

A
  • Genetic disorder resulting in a defective α-1 antitrypsin protein
  • Dx: confirmed w/ α-1 antitrypsin phenotyping

#1 cause of liver transplant in children!

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19
Q

α-1 antitrypsin proteins protect the liver & lungs from what?

A

neutrophil elastase–>enzyme that causes disruption of connective tissues, leading to inflammation, cirrhosis, and hepatocellular CA

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20
Q

How is alpha 1 antitrypsin deficiency treated

A
  • Tx: pooled α-1 antitrypsin is effective for pulmonary symptoms; doesn’t help with liver disease
  • Liver transplant is the only curative treatment
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21
Q

What is hemochromatosis?
What is the treatment

A

-Excess iron accumulation in body! Leads to multiorgan failure
Is genetic (excessive iron absorption) or may be caused by lots of blood transfusions or high dose iron infusions

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22
Q

Hemochromatosis: patients may present with what 5 conditions?

A

cirrhosis, heart failure, diabetes, adrenal insufficiency, or polyarthropathy

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23
Q

What’s the treatment for hemochromatosis?

A

Tx: weekly phlebotomy, iron chelating drugs, liver transplant

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24
Q

How is hemochromatosis diagnosed?

What are the labs?

A

Dx: genetic mutation testing
echo and MRI diagnose cardiomyoapthy and liver abnormalities.
Liver biopsy! may quantify iron levels and assess damage

Labs–> elevated ast/alt, transferrin saturation and ferritin

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25
# PSC What is primary sclerosing cholangitis? | Prevalent in men in their 40's
Autoimmune chronic inflammation of large bile ducts. - Fibrosis in biliary tree→strictures (beads on string appearance)→ cirrhosis, ESLD ## Footnote intrahepatic AND extrahepatic
26
How is PSC diagnosed? ## Footnote beads on string*
Dx: MRCP or ERCP showing biliary strictures w dilated bile ducts liver biopsy! but not always performed
27
Treatment for PSC? (primary sclerosing cholantitis?
Liver transplant! No drug treatment is effective. Reoccurence is common after transplane d/t auroimmune nature :(
28
What is cirrhosis? What are the symptoms
final stage of liver disease. Scarred liver! asymptomatic in early stages. Late symptoms are jaundice, ascites, varices, coagulopathy, encephalopathy.
29
What are common causes of cirrhosis (4)
caused by alcoholic fatty liver, NAFL, HCV, HBV
30
What are the labs seen in cirrhosis? How is it treated?
* Elevated labs: AST/ALT, bilirubin, Alk phosphatase, PT/INR * Thrombocytopenia Transplant is the only cure
31
What are complications of cirrhosis? (8)
-portal HTN (hepatic venous pressure gradient >5) -ascites -bacterial peritonitis -varices -hepatorenal syndrome -hepatic encepalopathy -hepatopulmonary syndrome -portopulmonary HTN
32
What is ascites? How is it managed?
Most common complication of cirrhosis. * Portal-HTN leads to ↑blood volume & peritoneal accumulation of fluid * Management: ↓Salt diet, albumin replacement TIPS-reduces pulmonary HTn and ascites
33
What are treatment of varices? ## Footnote Present in 50% cirrhosis patients
-BB help reduce risk endoscopic banding and ligation Balloon tamponade for bleeding
34
What is hepatic encephalopathy? What is the treatment?
* Buildup of nitrogenous waste d/t poor liver detoxification * Neuropsychiatric symptoms (cognitive impairment → coma) | Tx: Laculose, rifaximim to decrease ammonia
35
What is hepatorenal syndrome? What is the treatment?
** Excess endogenous vasodilators (NO, PGs)→ decrease systemic MAP and lower RBF! * Tx: Midodrine, Octreotide, Albumin
36
What is hepatopulmonary syndrome?
* Triad of chronic liver disease, hypoxemia, intrapulmonary vascular dilation * Platypnea (hypoxemia when upright) d/t R to L intrapulmonary shunt
37
What is portopulmonary HTN ? What is the treatment?
* Pulmonary HTN accompanied by portal HTN * Systemic vasodilation triggers production of pulmonary vasoconstrictors * Tx: PD-I’s, NO, prostacyclin analogs, and endothelin receptor antagonists * Transplant is only cure
38
What are the 2 scoring systems to determine severity and prognosis of liver disease?
*** Child-Turcotte-Pugh (CTP):** points based on bilirubin, albumin, PT, encephalopathy, ascites *** Model for End Stage Liver Disease** (MELD): score based on bilirubin, INR, creatinine, sodium
39
Elective surgery contradicted in what 3 diagnosis?
acute hepatitis, severe chronic hepatitis and acute liver failure
40
What is TIPS | Transjugular intrahepatic portosystemic shunt
-A stent/ graft placed between hepatic vein and portal vein. -shunts blood flow to systemic circulation and reduces portosystemic pressure gradient
41
What are TIPS indications? (2) Contraindications? (3)
Indications: variceal hemorrhage, regractory ascites Cx: HF, tricuspid regurgiation and severe pulm HTN
42
What is partial hepatectomy?
* Resection to remove neoplasms, leaving adequate tissue for regerenation Up to 75% removal is tolerated in patients w normal lvier!
43
What are anesthetic considerations in partial hepatectomy?
* Invasive monitoring * Blood products available * Adequate vascular access * maintain low CVP by fluid restriction, prior to resection to reduce blood loss -Surgeon may clamp IVC or hepatic artery to minimize blood loss -Prepare for post op coag disturbances -post op PCA
44
Intra op Managment of liver transplant ?
* Maintain hemodynamics (Pressors/Inotropes readily available) * A-line, CVC, PA cath, TEE * Control coagulation
45
Preop considerations in liver transplants?
Pre op evaluation, vascular access and blood product availability.
46
Intraop anesthesia considerations of liver disease?
High risk aspiration, hypotension, hypoxemia! Plasma cholinesteraase may be decreased and NMDR will be prolonged! Bleeding and coag managment
47
How does alcoholism affect MAC? Which NMB are preffered? Drugs onset and duration?
Alcoholism increases MAC of volatile anesthetics Succs and cisatracurium are ideal Drugs may have a slow onset and prolonged duration of action!
48
What to use for volume resuscitation in liver disease?
Colloids> crystalloids bc they are low in albumin and have low SVR
49
What to watch for during reperfusion of transplanted liver?
Watch for hemodynamic instability, dysrhythmias, hyperkalemia, acidosis, pulmonary emboli, and cardiac arrest
50
What are inborn errors of metabilism? What are the 3 disorders?
-Groups of genetical disorders that lead to a defect in the enzymes that breakdown and store protein, carbs and fatty acids -wilsons, alpha-1 antitrypsin deficiency and hemochromatosis` ## Footnote occurs in 1:2500 births
51
How is non alcoholic fatty liver diasese diagnosed? Tx? How does it progress?
Liver biopsy; hepatocytes contain >5% fat Tx: diet, exercise; Liver transplant indicated for advanced fibrosis and cirrhosis Progreses to non alcoholic steatohepatitis-> cirrhosis->hepatocellular carcinoma
52
What's the breakdown of oxygen delivery to the liver?
50% from portal vein (deoxygenated from GI organs, pancreas and spleen) 50% from hepatic artery
53
What is concerning about increased portal venous pressure?
blood backs up into systemic circ causing esophageal and gastric varices! ## Footnote portal venous pressure reflects splanchnic arterial tone and intrahepatic pressure
54
Hepatic arterial flow is inversly related to what? Hepatic artery dilates in response to ___________
portal venous blood flow! dilates in response to low portal venous flow, to keep consistent hepatic blood flow
55
What is normal portal venous pressure?
1-5 mmHg
56
What portal venous pressure is considered clinically significant portal HTN (leading to cirrhosis and esophageal varices)?
> 10 mmHg
57
What are the most liver-specific labs? What lab will be elevated in late stage liver damage?
AST + ALTs gamma-glutamyl-transferase (GGT; end stage liver)
58
How may the AST/ALT enzymes differ between the 3 types of hepatocellular injuries?
* Acute Liver Failure: ALT/AST may be elevated 25x * Alcoholic Liver Dz (ALD): AST:ALT ratio usually at least 2:1 * Non Alcoholic Fatty Liver Disease: ratio usually 1:1
59
How will you position pt for a lap chole?
reverse trendelenburg w/ a left tilt
60
How will you position pt for an ERCP?
prone with a left tilt, head to patient's right, tape ETT to left
61
What is unconjugated bilirubin?
Protein bound to albumin, transported into liver and conjugated into its H20 s**oluble "direct" state,** then excreted into bile | bilirubin: end product of heme breakdown
62
What's the difference between unconjugated and conjugated hyperbilirubinemia?
unconjugated: imbalance between bilirubin synthesis and conjugation (think physiologic jaundice of newborns, hgb disorders, hemolysis, drug-induced, sepsis) conjugated: caused by an **obstruction** that causes conjugated bili into circulation (think cholestasis, cirrhosis, congenital infections, obstructive jaundice)
63
What is the most common viral hepatitis requiring liver transplant in the US?
Hep C
64
Whats the treatment for hep C?
12 week course of sofosbuvir/velpatasvir provides 98-99% clearance of genotype 1a/1b
65
What plt count requires blood transfusion?
< 50K
66
When do ETOH withdrawal symptoms start to occur after they stop drinking?
24-72 hours
67
what are some s/s of alcoholic liver disease?
malnutrition, muscle wasting, parotid gland hypertrophy (CHIPMUNK CHEEKS!), jaundice, thrombocytopenia, ascites, hepatosplenomegaly, pedal edema
68
What is the most common cause of drug-induced liver injury?
acetaminophen overdose
69
How is alcoholic disease treated?
Managment of symptoms of liver failure! Transufsion <50,000 Plt count. -liver transfusion if criteria is met (2% of liver tx are for ALD)
70
What are the lab values for autoimmune hepatitis? Treatment??
+ autoantibodies and hypergammaglobulinemia AST and ALT 10-20 times normal Tx: steroids, azathioprine; Immunosuppression for refractory disaease, Liver tx may be indicated ## Footnote affects women; asymptomatic, acute or chronic
71
What are s/s of cholelithiasis? What’s the treatment
s/s: RUQ pain referred to shoulders, N/D, indigestion, feve Tx: IVF, antiopiotics, lap chole (reverse T w L tilt )

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