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Dental Management of the Medically Complex Patient > Hepatic Disease > Flashcards

Hepatic Disease Flashcards

1
Q

what is the largest internal organ and where is it located

A

the liver in the right upper quadrant

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2
Q

what is the dual blood supply to the liver and what percent does each contribute and what does each supply

A
  • 20% hepatic artery - oxygenated blood
  • 80% portal vein - nutrients
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3
Q

the right hepatic duct and the left hepatic duct come together to form:

A

the common hepatic duct

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4
Q

what does the common hepatic duct do

A
  • drains bile from the liver
  • transports waste from the liver and aids in digestion by releasing bile
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5
Q

what does the common bile duct do

A
  • carries bile from the liver and the gallbladder through the pancreas and into the duodenum
  • part of the biliary duct system; formed where the ducts from the liver and gallbladder are joined
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6
Q

where does the common bile duct drain into

A

the GI tract

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7
Q

what do the hepatic veins do

A

drain venous blood from liver to IVC and on to the right

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8
Q

what does the hepatic artery do

A

provides oxygen and nutrition to liver tissues

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9
Q

what does the hepatic portal vein do

A

delivers substances absorbed by the GI tract (stomach, intestine, spleen and pancreas) for metabolic conversion and/or removal in the liver

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10
Q

what are functions of hepatocytes

A
  • synthesizes proteins
  • bilirubin is from breakdown of RBCs
  • liver conjugates bilirubin by unbinding the protein binding it to glucose; this unconjugated from is in bile
  • produces bile for digestion
  • produces cholesterol for fat sotrage
  • regulates nutrients
  • prepares drugs for excretion
  • responsible for drug conjugation and metabolism
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11
Q

what proteins do hepatocytes synthesize

A
  • immunoglobulins
  • albumin
  • coagulation factors
  • carrier proteins
  • growth hormones
  • hormones
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12
Q

bilirubin is transported to liver by being bound to:

A

albumin (the unconjugated form)

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13
Q

bilirubin levels escalate from:

A
  • blood disorders
  • chronic liver diseases
  • blockage of bile ducts in liver or gallbladder
  • viral hepatitis, EtOH induced hepatitis, drug induced hepatitis, cirrhosis
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14
Q

what blood disorders can cause increased bilirubin levels

A
  • hemolytic anemia
  • sickle cell anemia
  • inadequate transfusions
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15
Q

what are symptoms of increased bilirbuin

A
  • jaundice
  • fatigue
  • cutaneous itch
  • discolored urine
  • discolored feces
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16
Q

what nutrients do hepatocytes regulate

A
  • glucose
  • glycogen
  • lipids
  • amino acids
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17
Q

what drug conjugation and metabolism are hepatocytes responsible for

A
  • bilirubin conjugation
  • phase I - cytochrone P450; can produce toxic metabolites
  • phase II - conjugation (glucoronidation, sulfation, inactivation by glutatione)
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18
Q

what are the types of liver damage

A
  • hepatocellular - inflammation and injury
  • cholestatic
  • mixed
  • cirrhosis (fibrotic, end-stage) ; acute or chronic
  • neoplastic
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19
Q

what are the types of liver disease

A
  • viral hepatitis (A, B, C, D, E, non A-E)
  • immune and autoimmune (primary biliary cholangitis, autoimmune hepatitis, GVHD)
  • genetic (alpha 1 trysin deficiency, wilson disease)
  • NAFLD (obestiy, insulin resistance, lipodystrophy)
  • cholestatic syndromes
  • systemic disease with liver involvement (sarcoidosis, amyloidosis, TB, glycogen storage disease)
  • drug induced liver disease
  • hepatocellular carcinoma
  • masses, cysts, abscess
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20
Q

what are the signs of liver disease

A
  • jaundice
  • ascites
  • edema
  • GI bleed
  • dark urine
  • light stool
  • mental confusion
  • xanthelasma
  • spider angiomas
  • palmar erythema
  • asterixis
  • hyperpigmentation
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21
Q

what are the symptoms of liver disease

A
  • appetite loss
  • bloating
  • nausea
  • RUQ pain
  • fatigue
  • mental confusion
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22
Q

what is a coincident sign and symptom of liver disease

A

mental confusion

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23
Q

what are xanthelasmas

A

fatty deposits on the eyes from chronic liver disease history

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24
Q

what conditions can happen with liver disease

A
  • xanthelasmas
  • spider angiomas
  • asterixis
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25
Q

what is asterixis and what is it also known as

A
  • AKA flapping tremor
  • classic sign in hepatic encephalopathy
  • jerky movements when hands are extends at wrists
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26
Q

what is asterixis from

A

indirect effect of liver disease- liver does not synthesize ammonia to ammonium for excretion and it gets into the blood stream

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27
Q

what is hepatic encephalopathy

A

a syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in patients with severe liver disease

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28
Q

what is the progression of hepatic encephalopathy

A
  • can be a chronic problem in patients with cirrhosis managed medially to varying degrees of success, punctuated with occassional exacerbations
  • acute exacerbations are rarely fatal but they are a frequent cause of hospitalizations among patients with cirrhosis
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29
Q

what are the blood tests for liver function

A
  • CBC
  • CMP
  • lipid panel
  • VDRL
    -PSA
  • SARS
  • bleeding times
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30
Q

what cells are evaulated in a CBC

A
  • RBCs
  • WBCs
  • platelets
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31
Q

what does a CBC tell us

A
  • indicator of overall health
  • may detect infection, anemia, leukemia, lymphoma, neutropenia
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32
Q

what are other names for CMP

A
  • chemical screen
  • SMAC 14 (sequential multiple analysis computer)
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33
Q

what does a CMP test

A
  • 14 blood tests which serve as an initial broad medical screening tool
  • general tests
  • kidney function assessments
  • electrolytes
  • protein tests
  • liver function assessment
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34
Q

what are the other SMAC variants

A

8, 12, 16, and 20

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35
Q

the more you analyze in blood tests the more ______

A

expensive

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36
Q

what proteins can be tested that are involved in liver function

A
  • bilirubin
  • alkaline phosphatase (ALP)
  • transaminases: aspartate amino transferase (AST), alanine amino transferase (ALT), gama- glutamyl transferase (GGT)
  • albumin
  • globulin
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37
Q

bilirubin is a product of ____ breakdown

A

heme

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38
Q

increased total bilirubin means increased:

A

severity of liver injury

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39
Q

describe unconjugated (indirect) bilirubin and what does it indicate

A
  • insoluble, bound to albumin, not filtered by kidney
  • increased serum not really indicative of liver disease
  • indicates hemolysis, ineffective erythropoiesis (thalassemia, vitamin B deficiency, Gilbert syndrome)
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40
Q

describe conjugated bilirubin (direct) and what it indicates

A
  • increased serum indicative of liver disease
  • water soluble, excreted by kidney
  • all urine bilirubin is conjugated
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41
Q

describe alkaline phosphatase and what an elevated level of it may indicate

A
  • altered in myriad of diseases especially bone neoplasms
  • not specific to liver disease
  • may indicate cholestatic disease
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42
Q

what is AST related to

A

glutamic oxalate metabolic pathways

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43
Q

what is ALT related to

A

part of pyruvate pathway in cell metabolism

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44
Q

what is gama- glutamyl transferase used for

A
  • needed for protein synthesis
  • useful to detect alcohol induced liver cell injury and chronic alcoholics
  • can detect the slightest degree of colestasis
  • sensitive to biliary obstruction, cholangitis, and cholecystitis
  • good marker for pancreatic cancer, prostatic carcinoma, and liver cell carcinoma
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45
Q

what do high levels of transaminases indicate

A

damage to hepatocytes from hepatocellular disease
- does not reflect severity of liver damage
- up to 300 UI/L -> non specific

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46
Q

what does the AST: ALT ratio tell us

A

the lower the ratio, the more specific an indicator of hepatic disease

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47
Q

what exclusively synthesizes albumin

A

hepatocytes

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48
Q

what is the half life of albumin

A

18-20 days

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49
Q

what does hypoalbuminemia tell us

A
  • more indicative of chronic liver disease
  • not specific only to liver disease- it also tells us about malnutrition, chronic infection and gut disease
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50
Q

the liver produces all coagulation factors except

A

factor 8

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51
Q

PT time measures factors:

A

I, II, V, VII, and X

52
Q

what are the vitamin K dependent coagulation factors

A

II, VII, IX and X

53
Q

what are the tests in a CMP

A
  • albumin
  • alkaline phosphatase
  • ALT
  • AST
  • BUN
  • Calcium
  • Chloride
  • CO2
  • creatine
  • glucose
  • potassium
  • sodium
  • total bilirubin
  • total protein
54
Q

which viral hepatitis is not an RNA virus? what type of virus is it

A

Hep B is a enveloped DNA virus

55
Q

what is hepatocellular damage and what happens in it

A
  • host immune response to viral antigens rather than direct cytopathic effect from virus
  • cytotoxic T_cells
  • proinflammatory cytokines
  • natural killer cell response
  • antibody dependent cellular cytotoxicity
56
Q

viral hepatitis infection ranges from:

A

asymptomatic/symptomatic to acute/chronic

57
Q

what are the possible fates of viral hepatitis viruses

A
  • pt may clear the virus or virus may become inactive
  • reactivation may occur
58
Q

chronic hepatitis can lead to:

A
  • cirrhosis
  • liver failure
  • hepatocellular carcinoma
  • risk factor for immunosuppression
59
Q

what is it called when a hepatitis infection is chronic but asymptomatic

A

carrier state- low levels of the virus

60
Q

how long can Hep B last

A
  • up to 7 days on an infected surface
  • incubation period is 90 days on average
61
Q

what is the chronicity for Hep B

A
  • 90% for infants
  • 25-50% in children (1-5)
  • less than 5% in adults
62
Q

what is the vaccination for Hep B

A

3 doses- initial - 1 month and 6 months

63
Q

can hep b be reactivated

A

yes

64
Q

what is the treatment for Hep B

A

peg interferon or antivirals such as entecavir and tenofovir

65
Q

how long is the surface antigen present in chronic cases of hepatitis

A

always

66
Q

how long is the surface antigen present in acute cases of hepatits

A

only in the early phases

67
Q

describe the prevalence of Hep C

A
  • average prevalance in injection drug user is 53%
  • baby boomers should be screened- higher risk of having virus
  • 15-25% of untreated patients clear the virus
68
Q

what is the risk of Hep C becoming chronic and what are the risks of chronic hep C

A
  • 75-85%
  • 10-20% develop cirrhosis but takes 20-30 years
  • increased risk for hepatocellular carcinoma
  • increased risk of death
69
Q

does HIV or HCV have a higher needlestick transmission rate

A

HCV

70
Q

is there a vaccine fro HCV

A

no

71
Q

what is the a cure for HCV

A

12 weeks of protease inhibitor therapy
- mavyret
- epclusa
- harvoni

72
Q

describe Hep D

A
  • usually coninfection with HBV
  • more severe than HBV alone
  • higher risk of fulminant hepatitis
  • massive hepatocellular destruction
73
Q

describe hep A and Hep E

A
  • infectious hepatitis, fecal-oral transmission
  • highly contagious and transmissible
  • vaccination available for HAV
  • mortality not as high
74
Q

what can chronic. liver dysfunction cause

A
  • increased bleeding
  • altered drug metabolism
75
Q

what is the most likely viral hepatitis to be transmitted occupationally to a dental healthcare worker

A

Hep B then Hep C

76
Q

is there a big risk for transmission of HAV, HEV to dentists

A

no

77
Q

reduce oral healthcare worker infection by:

A
  • all patients are considered infectious -> standard precautions
  • HBV vaccination
78
Q

what do you need to determine in viral hepatitis patients

A

-circumstances of infection - age of onset, source of infection
- status of viral hepatitis- serology, is it treated, viral load

79
Q

what should you do with patients with active hepatitis

A
  • defer all elective dental treatment
  • if emergency treatment: consult with physician, determine severity of disease and dental treatment risk, consider referral, isolation
80
Q

what should you do with resolved, chronic inactive patients with history of hepatitsi

A
  • consider risk factors
  • consult with physician to determine liver status
81
Q

what should you do if you are stuck with a needle of a hepatitis pateint

A
  • consult with physician
  • get the immunoglobulin
82
Q

what are the oral manifestations of viral hepatitis

A
  • bleeding
  • mucosal jaundice
  • glossitis
  • angular cheilosis
  • extrahepatic immunologic disorders with chronic HCV such as lichen planus and lymphocytic sialadenitis
83
Q

what is the mechanism of drug induced liver disease

A
  • direct toxicity to hepatocytes
  • production of hepatotoxic metabolites
  • accumulation of drug to altered metabolism
84
Q

alcohol and its metabolite are ______

A

hepatotoxic

85
Q

what does alcohol do to the liver

A

causes inflammation

86
Q

what is the progression of alcoholic liver disease

A
  • takes 10 years of excessive alcohol intake to develop
  • patients first develop fatty liver - reversible
  • continual alcohol use and ensuing inflammation can lead to irreversible changes and necrosis
  • eventually with continual use, fibrosis and cirrhosis develop- irreversible- leading to hepatic failure
87
Q

wwhat are the complications of alcoholic liver disease

A
  • bleeding tendencies- alcohol can impair platelet function
  • unpredictabe drug metabolism
  • potential impaired immune function
  • peripheral neuropathies
  • dementia and psychossis
  • anorexia
88
Q

what are the complications of cirrhosis

A
  • ascites - hepatorenal syndrome
  • esophageal varices
  • jaundice
  • hepatosplenomegaly
  • coagulation disorders
  • hypoalbuminemia
  • anemia
  • neutropenia
  • encephalopathy
89
Q

what is hepatosplenomegaly

A
  • enlarged spleen due to portal hypertension
  • decreased platelet function
  • leads to thrombocytopenia
90
Q

what happens in coagulation disorders

A
  • decreased synthesis of clotting factors
  • impaired clearance of anticoagulants
  • decreased vitamin K absorption
91
Q

what are the types of anemia caused by alcoholic liver disease

A
  • iron deficiency
  • macrocytosis
92
Q

what causes encephalopahty

A

neurotoxins not removed from the liver

93
Q

how can you identify alcoholic patients

A
  • history
  • clinical exam
  • detection of odor on breath
  • suspicious behavior
  • information from family/friend
94
Q

describe metabolism during early on/mild liver dysfunction in alcoholic liver disease

A

liver enzyme induction may increase metabolism of prescribed drugs limiting their effect

95
Q

describe metabolism in severe liver dysfuction

A

drug metabolism may be hindered and drug toxicity is a concern

96
Q

what are the main feautres of cirrhosis

A
  • encephalopathy: confusion, coma, asterixis
  • spider nevi
  • coagulopathy
  • ascites
  • increased risk of hepatocellular carcinoma
97
Q

are patients with suspected, active, untreated alcoholic liver disease candidates for routine elective dnetal tx

A

no

98
Q

oral neglect is common in those who _____

A

abuse alcohol

99
Q

what levels suggest alcoholic liver disease

A

AST: ALT ratio less than 2 and elevated GGT

100
Q

what are the values of total protein, globulin, A/G ratio, alkaline phosphatase, ALT and AST in hepatitis

A
  • total protein: normal
  • albumin: normal
  • globulin: normal
  • A/G ratio: greater than 1
  • alkaline phosphatase: elevated
  • ALT: increased
  • AST: increased
101
Q

ALT is always _____ than AST

A

greater

102
Q

what are the values of total protein, globulin, A/G ratio, alkaline phosphatase, ALT and AST in cirrhosis

A
  • total protein: decreased
  • albumin: decreased
  • globulin: increased
  • A/G ratio: less than 1
  • alkaline phosphatase: elevated
  • ALT: increased
  • AST: increased
103
Q

what are the oral manifestations of alcoholic liver disease

A
  • neglect
  • bleeding
  • ecchymoses
  • petechiae
  • glossitis
  • angular cheilosis
  • alcohol odor
  • parotid enlargement
  • xerostomia
104
Q

wha tis the number one abused drug in terms of ER visits, hospital admission , family violence and other social problems

A

alcohol

105
Q

alcohol abuse is a strong risk factor for what cancer

A

oral squamous cell carcinoma

106
Q

what does the breath of an alcoholic smell like

A

sweet and musty

107
Q

what tests should be done to evaluate the fitness of the patient for dental treatment in liver disease

A
  • CBC with differential
  • liver function test
  • bleeding studies
108
Q

what liver function tests should be included in a liver disease patient

A
  • AST
  • ALT
  • GGT
  • albumin
  • alkaline phosphatase
  • bilirubin
109
Q

what bleeding studied should be ordered in a liver disease pt

A
  • PT
  • bleeding time
110
Q

what should you do with a paitent with acute liver disease

A
  • treat on emergency basis only
  • consult with phsycician
  • if severe liver disease and requires emergency tx refer to center
111
Q

what history should you gather in a pt with liver disease

A
  • age of onset
  • consult wtih physician to determine status and medication
  • compensated disaeaase or decompensated disease
  • assess other end organ damage such as: gallbladder, renal, CV, hematologic disease
112
Q

what are the preoperative strategies to deal with bleeding complications in a pt with liver disease

A
  • consult with physician concerning liver disease status
  • review meds to assess possible medication related bleeding risk
  • request relevant labs and check results to confirm if it is safe to proceed
113
Q

what are the peri/intra operative strategies to deal with bleeding complications in a pt with liver disease

A
  • perform extractions as atraumatically as possible
  • if perfroming a SRP do one tooth at a time rather than an entire quad
  • have local hemostatic agents available
  • place sutures in all extraction sites
114
Q

what are the local hemostatic agents

A
  • surgicel, gelfoam
  • topical thromin
  • tranexamic acid
  • bone wac
  • electrocautery
  • silver nitrate sticks
  • aminocaproic acid rince
115
Q

what are the post operative strategies to deal with bleeding complications in a pt with liver disease

A
  • pt sit in chair for 20 minutes after procedure and assess that local hemostasis is good
  • explain verbally and have written post op instructions available for the pt
  • do not prescribe NSAIDS
  • can give up to 2 mg of acetominophen daily
  • supply pt with gauze
  • reinforce the need to maintain clot in place- no straws, no spitting, avoid taking and maintain soft diet for 2-3 days
  • call if bleeding persists
116
Q

when is antibiotic prophylaxis required

A

when oral infection is present

117
Q

should you give AB prophylaxis to severe liver disease patient for surgical procedures and why or why not

A

yes due to decreased immune function

118
Q

what drugs should you not give and which can you give

A
  • minimize drugs metabolized by the liver
  • local anesthetic
  • analgesics
  • sedatives
  • antimicrobials
  • avoid benxodiazepines
  • lorazepam may be used
  • nitrous may be used
  • esters okay!!!
119
Q

what can high doses of acetominophen lead to

A

toxicity and liver failure

120
Q

if opioids are necessary what is the preferred choice and why

A

hydromorphone because of glucoronidation

121
Q

why should you avoid hydrocodone and oxycodone

A

unpredictable metabolism

122
Q

what antimicrobials should you avoid in pt with liver disease

A
  • metronidazole
  • tetracycline
  • doxycycline
  • antifunglas
  • clindamycin
    no alcohol with antibiotics - 2nd and 3rd generation cephalosporins- disulfiram effect, can cause extreme vomitting
123
Q

what are the cautions with portal hypertension in liver disease pt

A
  • BP can be elevated with portal HTN
  • limit EPI
  • do not use retraction cord with epi
  • thrombocytopenia
124
Q

what is the weight risk: benefit ratio in severe liver disease patients

A

impairment of drug metabolism : immune impairment

125
Q
A

Dental Management of the Medically Complex Patient (13 decks)

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