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Acute Care Seminar 1 > Hepatobiliary Disorders > Flashcards

Hepatobiliary Disorders Flashcards

(56 cards)

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1
Q

Hep A Risk Factor

A

contaminated food or water, fecal-oral

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2
Q

Hep B Risk Factor

A

-residence/travel to Southeast Asia, Africa, blood and body fluid transmission
-Most recover w/out complications
-Antiviral meds: Entecavir, Tenofovir, Interferon

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3
Q

Hep C Risk Factor

A

-IV injection or drug use, blood product before 1990
-Antivirals: Adefovir, entecavir, tenofovir
-Interferon

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4
Q

Hep D Risk Factor

A

only occurs with Hep B, blood or body fluid transmission

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5
Q

Hep E Risk Factor

A

contaminated food or water, fecal-oral, Southeast Asia

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6
Q

Medical Hx to Ask

A

-Dark urine
Pale stools (suggest obstruction)
Arthralgia, myalgia, or rash (? Viral etiology)
Anorexia or weight loss
Abdominal pain
Fever
Itching
Abdominal distension

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7
Q

Portal Vein

A

-carries nutrient-rich blood from the intestine and other parts such as the gallbladder, pancreas and spleen to the liver

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8
Q

Hepatic Vein

A

-carries deoxygenated blood from the liver to the vena cava.

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9
Q

Hepatic Artery

A

supplies oxygen-rich blood to the liver, duodenum, and pancreas.

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10
Q

Bile Duct

A

carries bile from the liver to the small intestine to help with digestion

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11
Q

Liver Physiology

A

-Protein Synthesis
-Detoxification
-Bile Production
-Glucose regulation
-Production of cholesterol
-Vitamin storage
-Iron storage

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12
Q

Liver Disease-PE

A

-Jaundice
JVP (elevation suggests hepatic congestion from right heart failure)
-Lung examination for right pleural effusion
-Shifting dullness and fluid wave (though these are poor predictors for ascites)
-Abdominal tenderness or positive Murphy sign

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13
Q

Hepatocellular

A

-Damage from liver cells
-AST, ALT > than Alk Phos
-Serum bilirubin may be elevated
-Synthetic function maybe abnormal (INR, albumin)

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14
Q

Cholestatic

A

-Decrease in bile flow due to obstruction
-Alk Phos (ALP, Alk Phos) > AST, ALT
-Serum bilirubin maybe elevated
-Maybe abnormal INR and albumin

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15
Q

Alanine Aminotransferase (ALT)

A

-Hepatocellular injury
-“L” is for liver
-also found in skeletal muscle and kidney disorders, more “liver” specific
-Male – 10-55 international unit/L
-Female 7-30 international unit/L

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16
Q

AST - aspartate aminotransferase

A

-Hepatocellular Injury
-also found in the heart, skeletal muscle, kidneys, brain, and red blood cells
-Male – 10-40 international unit/L
-Female – 9-32 international unit/L

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17
Q

AST/ALT Ratio

A

-Most common to have AST < ALT for liver dysfunction
-Remember, ALT is more liver specific

> 2:1 highly suggestive alcoholic disease
Ex: AST 200, ALT 100
-May also be seen in fatty liver (nonalcoholic steatohepatitis)

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18
Q

AST/ALT Ratios in Acute Viral Hepatitis

A

-AST and ALT >25x upper limit of normal (1,000)

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19
Q

Nonalcoholic Steatohepatitis (NASH)

A

-AST and ALT <4 times upper limit of normal (160)
-Do US and liver biopsy
-Many asymptomatic
-Hepatomegaly, fatty liver on biopsy, exclusion of alcohol or other causes

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20
Q

Alcoholic Fatty Liver Disease

A

-AST < 8 times upper limit of normal (320), ALT < 5 times upper limit of normal (200)
-Biopsy, US
-Should improve with cessation of alcohol

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21
Q

AST/ALT Ratios in Ischemic or Drug Induced Hepatitis

A

-AST and ALT > 50 times upper limit of normal (2,000)
-Rhabdomyolysis (polymyositis, seizure)
-Budd-Chiari syndrome
-Sepsis
-Hx of severe Hotn
-Rapid improvement of aminotransferases-dx test

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22
Q

Alkaline Phosphatase

A

-Cholestatic Pattern
-Normal: 20-140 IU/L
-Also found in bone and placenta
-Isolated Alk Phos if AST & ALT normal
-Hyper parathyroidism/Thyroidsim

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23
Q

Glutamyltransferace GGT

Study These Flashcards
A

-most sensitive enzymatic indication of liver disease
-Check if ALP is elevated to distinguish primary liver etiology
Normal 9-48 U/L
-Can be used as screening for alcohol use

24
Q

Isolated Alkaline Phosphatase

Study These Flashcards
A

-Normal GGT with elevated ALP
-Warrants further eval of non hepatic causes (skeletal)
-Refer to endo
-Pagets disease
-Healing Fracture
-Osteomalacia

25
Bilirubin
-Total Bilirubin: 0.1-1.2 mg/dL-combo of direct and indirect -Substance found in bile, digests fats -Results from breakdown of old red blood cells -Excreted in bile and urine -Gives the stool its normal brown color
26
Conjugated Bilirubin
-Direct Bilirubin: < 0.3 mg/dL -Increased due to decreased excretion into the bile ducts -Leakage of pigment from hepatocytes into serum -----Isolated conjugated Bilirubin Dubin-Johnson syndrome -Rotor syndrome Present with asymptomatic jaundice, 20s
27
Unconjugated Bilirubin
-Indirect: Normal 0.3-1.0 mg/dL -Increase level is due to overproduction, impaired uptake, or inability to conjugate -Impaired uptake: med induced -Bilirubin overproduction-hemolysis (decreased haptoglobin, elevated LDH)
28
Prolonged INR
-Med induced -Hepatocellular function -Vit K deficiency ->1.1
29
Albumin
-Hepatocellular function -3.4-5.4 g/dL -Low-chronic process -Normal-acute process
30
Ammonia
-Primary source of ammonia is through GI tract -Liver converts ammonia to urea, then excreted through stool -Elevated in non hepatic conditions Shock, Heavy exercise Renal disease, After chemo GI bleed
31
Hematochromatosis (Iron)
-Body absorbs too much iron from food -Clinical cues: arthritis, diabetes, family hx -Dx tests: iron studies, genetic testing, liver biopsy
32
Wilson's Disease
-Body absorbs and can’t eliminate copper -Neuro s/s, hemolysis -Dx tests: Cerulosplasmin, urine copper -Tx: Chelating agents – bind to copper and released in urine, Zinc acetate
33
Alpha-1 Antitrypsin Deficiency
-Genetic condition -Deficiency in protein leads to damage of hepatocytes and alveolar walls -Often coincides with early onset emphysema in nonsmokers -Tx: Supportive therapy of COPD and liver failure
34
Primary Biliary Cirrhosis (PBC): Cholestatic Liver Disease
-Chronic and progressive destruction of the small bile duct -Autoimmune process -middle aged, fatty deposits skin, nails, palms, elbows, knees, diarrhea, elevated cholesterol, hypothyroidism, osteoporosis -Dx: Antimitochrondrial antibody, antinuclear antibody, MRCP -Tx: Ursodiol, Cholestyramine
35
Primary Sclerosing Cholangitis (PSC): Cholestatic Liver Disease
-Destruction of the larger biliary tree leading to strictures -Prone to cholangitis -Associate w/ ulcerative colitis -Dx: Cholangiography -Tx: ERCP with balloon dilation w/ or w/o stenting Cholestyramine Ursodiol
36
Large Bile Duct Obstruction: Cholestatic Liver Disease
-RF: pregnant, estrogen, DM, fm hx, age, female, inactivity, obesity w/ rapid wt loss -Jaundice & pain in right shoulder, epigastric to RUQ -Dx: US, cholangiography
37
Acute Cholecystitis
-Inflammation of the gallbladder -Blockage of the gallbladder by a stone -+fevers, +pain, + Murphy’s sign
38
Acute Cholecystitis: Choledocholithiasis
stone in the common bile duct
39
Acute Cholecystitis: Cholangitis
-infection of the bile duct -Fever, chills, etc. -Need IV abx -Gallbladder removal, ERCP Pancreatitis
40
Acalculous Cholecystitis
-Cholecystitis without a stone -Gallbladder stasis or ischemia -High morbidity and mortality -US (no stones, thick gallbladder wall, perforation, gallbladder distention, emphysematous), HIDA scan (look at EF of the liver) -Abx therapy -Cholecystectomy versus cholecystostomy tube placement
41
Acetaminophen and Liver disease
-Drug induced -AST >5000 U/L
42
Portal Htn
-Chronic disease leads to liver fibrosis -Progressive fibrosis slows portal blood flow through liver and pressure begins to build within the portal system -Causes increase protal venous resistance as blood returns to the heart
43
Hepatic Encephalopathy: Tx
-Treating underlying cause -Lactulose 15-30 grams 3-4x/day -Rifaxamin 550 mg twice per day -Lactulose 1000 mg retention enema (advanced HE)
44
Esophageal Varices
-Screening required for patients with cirrhosis -Abnormal veins in the lower part of the esophagus -Esophageal varices usually develop when blood flow to the liver is blocked.
45
Small to Medium Esophageal Variceal Bleed
-Start nonselective beta-blocker -Decrease portal system hypertension -Propranolol 60 mg daily or -Nadolol 20 mg daily -Consider dose at bedtime, keep SBP >90
46
Medium to Large Esophageal Variceal Bleed
-Start with nonselective BB -May need endoscopic variceal ligation -Propranolol LA 60mg qd -Nadolol 20mg qd
47
Esophageal Variceal Hemorrhage
-Fluid & RBC resuscitation -Ppx Abx (ceftriaxone 2g q 24 hrs) -Octreotide 50 mcg IV bolus then 50 mcg/hr -Protonix 40 mg IV BID -Reverse coagulopathy -GI consultation -If ascites present, obtain paracentesis to evaluate for SBP -Avoid NSAIDS, ASA, Ginko biloba -Sengstaken-Blakemore tube, minnesota tube (more current)
48
Octreotide
inhibits release of splanchnic vasodilator = reduced splanchnic blood flow and portal venous pressure
49
Correction of Coagulapthy
-Depends on coags and location & severity of bleed -Acute variceal bleed 10 mg vit K IV 1 mg/min Plt goal >50,000 FFP vs Cryo Consider checking TEG
50
Transjugular intrahepatic portosystemic shunt (TIPS)
Creates a pathway through the liver that connects the portal vein to hepatic vein = reduced portal hypertension
51
Ascites
Common complication of liver disease Natural progression of disease – as ascites develops, increased mortality after development Often coincides with peripheral edema
52
Ascites Management
-Low sodium diet of < 2 grams sodium per da -Lasix 40 mg daily and/or Spironolactone 100 mg daily -Monitor sodium and creatinine closely! -ACE wraps for peripheral edema -Paracentesis: should be done on all hepatic ascites even if no infection (gram stain, protein count, neutrophil count, culture)
53
Replacement of Albumin: After large vol. paracentesis
6-8 grams of 25% albumin per liter of fluid removed
54
Hepatorenal Syndrome
-Potential caues of AKI in pts w/ cirrhosis -Arterial vasodilation within spleen is triggered by portal htn--causes renal vasoconstriction and decreased perfusion to kidneys -Brought on by acute illness (infection, GIB, encephalopathy)
55
Hepatorenal Syndrome Clinical Presentation
-Rise in serum creatinine > 0.3 from baseline -Proteinuria < 500 mg/24 hours -Hematuria -Renal US negative for obstruction -< 500 mL UOP per day -Urine sodium < 10 meq/L -Urine Osmolality > Plasma Osmolality
56
Hepatorenal Syndrome: Management
-Ideal is to improve liver function -Hold diuretics -Critical Illness in ICU (pressors) -NonICU; Midodrine, albumin, octreotide -TIPS candidate? -Liver transplant -Need for dialysis

Acute Care Seminar 1 (31 decks)

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