L19: Management Of Liver Disease (Hill)

Question 1

Which breeds prone to extrahepatic congenital PSS?

Answer 1

Lhasa
Shih Tsu
Schnauzer
Yorkie

Question 2

Which breeds prone to intrahepatic congenital PSS?

Answer 2

Irish wolfhound
Irish Setter
Labs

Question 3

Which breeds prone to microvascular dysplasia?

Answer 3

Yorkies

Cairn terriers

Question 4

Congenital hepatic vascular abnormalities

Answer 4

Extrahepatic PSS
Intrahepatic PSS
Microvascular dysplasia (many small shunts)
AV fistula

Question 5

Tx of PSS

Answer 5

Ligation or coil for shunt if congenital with no portal hypertension

• 6% die with sx
• use keppra to prevent seizuring
• sx should be considered if bile acids are increased, which is an indication that treating the shunt will give the dog more functional liver

Question 6

Common liver toxins that cause ACUTE to FULMINANT hepatic necrosis

Answer 6

• acetaminophen
• caparsolate (old heartworm tx)
• blue green algae
• sago palm
• moldy food
• amanita mushrooms

*prognosis poor with fulminant necrosis

Question 7

Common liver toxins that cause CHRONIC hepatic changes

Answer 7

• oxibendazole and DEC
• Carprofen
• Phenobarb
• Primidone
• phenytoin

Question 8

Acute tx of toxin exposure

Answer 8

• if hypoxic, restore airway, breathing, circulation
• remove toxin (ie. Dialysis)
• give antidote/tx for specific toxins

Question 9

Antidote to amanita poisoning

Answer 9

Sylimarin

Question 10

Antidote to acetaminophen toxin

Answer 10

Acetyl cysteine

Question 11

Tx of copper and iron toxicity

Answer 11

• penicillamine
• trientene
• Zinc (inhibits Cu absorption)
• Cu restricted diet (l/d

Question 12

CS of Cu deficiency

Answer 12

Similar to Fe deficiency anemia

-also: cardiac dz, low WBCs

Question 13

Forms of hepatic lipidosis in cats

Answer 13

• idiopathic (most common)

- secondary (2ary to DM, hypothyroidism, pancreatitis/triaditis)

Question 14

Tx of hepatic lipidosis in cats

Answer 14

• tx underlying cause (ie. IBD)
• E-tube and introduce high protein, high fat food slowly (high protein helps export fat from liver)
• monitor for refeeding syndrome (excess glucose goes to liver and gets converted to fat)
• tx atypical cushings with melatonin and/or lysodren in diet

Question 15

Forms of infectious hepatitis

Answer 15

• viral
• bacterial
• protozoal
• fungal

Question 16

3 viral hepatitidies

Answer 16

CAV-1
Acidophil cell hepatitis
FIP

Question 17

Bacterial hepatitidies (and tx)

Answer 17

Lepto: penicillin, doxy
Bartonella: enrofloxacin, doxy, azythromycin

Question 18

Protozoal hepatitidies and tx

Answer 18

Leishmania: allopurinol
Toxoplasma: TMS, pyrimethamine
Hepatozoon: Imidocarb

Question 19

Clinical approach to liver flukes

Answer 19

Platynosomum concinnum

• causes bile duct obstruction, pancreatitis, chronic liver dz
• can cause acute AND chronic disease
• tx: high dose praziquantel
• may or may not get quick resolution w/ tx

Question 20

Clinical approach to cholecystitis

Answer 20

• caused by ascending or systemic infection (usually E. Coli)
• usually a benign finding
• choleliths are less common cause
• tx: abx and supportive care if milder, cholecystectomy if severe
• prognosis guarded to poor

Question 21

Clinical approach to Feline cholangiohepatitis

Answer 21

• usually caused by anaerobes and Gram - bacteria ascending from biliary tree
• GB can leak and cause bile peritonitis
• Dx by biopsy and culture
• can be suppurative (neuts) or non-suppurative (lymphs)
• Tx: abx (clavamox) +/- prednisone if non-suppurative over 3-4+ months

Question 22

Ursodeoxycholic acid (ursodiol)

Answer 22

• hydrophobic bile acid that displaces endogenous hydrophobic bile acids that accumulate in cholestatic dz
• anti-inflammatory, increases bile flow
• originally from bears
• contraindicated if complete obstruction
• very expensive

Question 23

Surgical biliary diseases

Answer 23

• biliary obstruction: tumor, gall stones
• Emphysematous cholecystitis
• Mucocele

*very guarded prognosis (7-50% mortality rate), since by the time we remove GB it is very diseased

Question 24

Primary hepatic neoplasia

Answer 24

Hepatoma
Bile duct carcinoma
Tx: sx, since has poor response to chemo (P glycoprotein) - liver naturally gets rid of chemo

Question 25

Top 3 metastatic hepatic neoplasms

Answer 25

LSA HSA MCT

Question 26

Breed disposition of idiopathic chronic hepatitis

Answer 26

Doberman Cocker spaniel Westies

Question 27

Etiology of idiopathic chronic hepatitis

Answer 27

Unknown (possibly immune-mediated)

Question 28

Dx of idiopathic chronic hepatitis

Answer 28

Biopsy showing bridging necrosis, lymphocytic-plasmacytic infiltration progressing to cirrhosis Very guarded prognosis

Question 29

Tx of idiopathic chronic hepatitis

Answer 29

1) Immunosuppressive therapy: -prednisolone/budesonide (mineralocorticoids) -Dexamethazone if have ascites +/- azathioprine *prednisolone better than prednisone* 2) Antifibrotic therapy: Colchicine 3) Herbal remedy: Sylimarin (milk thistle) 4) Supportive therapy

Question 30

Colchicine

Answer 30

- microtubule inhibitor for idiopathic chronic hepatitis - inhibits collagen deposition, stimulates collagenase, may decrease inflammation - no objective data to support efficacy

Question 31

Sylimarin (milk thistle) for idiopathic chronic hepatitis

Answer 31

- antioxidant, leukotriene, and TNF inhibitor - inhibits P glycoprotein and P450 enzymes - uncertain efficacy/dose

Question 32

Supportive therapy for idiopathic chronic hepatitis

Answer 32

Fluids: glucose, no lactate (met. In the liver) Plasma (binds amino acids and things that get transformed into neurotransmitters) Nutrition Antioxidants (Vit. E) S-adenosyl methionine (SAMe)

Question 33

Nutrition for tx of idiopathic chronic hepatitis

Answer 33

- high protein (unless has PSS or chronic cirrhosis) - folate, B12, SAMe for methyl transfer - Choline for phospholipid export - Vitamin K for bile obstruction

Question 34

Oxidation important mech. For continued damage in cholestatic and other liver diseases due to:

Answer 34

Divalent cations, kupfer cells, bile acids Prevent with Vitamin E and C

Question 35

Too much Vitamin E can -->

Answer 35

Inhibit Vitamin D and K absorption

Question 36

Methyl transfer cycle, and how affected by liver failure

Answer 36

Methionine --> SAMe --> S-adenosyl Homocysteine --> Homocysteine --> Methionine *liver failure prevents methionine --> SAMe (So may need to supplement SAMe in liver failure patients)

Question 37

Liver damage reduces methylation reactions which synthesize:

Answer 37

- nucleic acids and amino acides - phosphatidylcholine - polyamines and GSH

Question 38

Denosyl =

Answer 38

SAME | -give 1 hr. Before feeding

Question 39

Symptomatic therapy of idiopathic chronic hepatitis

Answer 39

- appetite stimulants - antiemetics - mucosal protection - Rx for hepatic encephalopathy and/or ascites**

Question 40

Causes of neurological signs

Answer 40

- ammonia from colon and kidney - inhibitory GABA receptor stimulation of endogenous benzodiazepine ligands (benzos, barbiturates) - false neurotransmitters - methionine/mercaptons - hypoglycemia (tx first) - cerebral edema (tx w/ mannitol) - hypokalemic alkalosis (K trapped intracellularly) - dehydration

Question 41

Tx of hypokalemic acidosis

Answer 41

Give potassium

Question 42

Sources of protein (and urea) in the large intestine

Answer 42

- indigestible protein in the diet | - blood from gastric ulceration

Question 43

Prevention of protein in the large intestine

Answer 43

- decrease protein in diet - use digestible protein with good balance (ie. Egg, mixed protein, cottage cheese, veggie protein) - avoid meat protein - give mucosal protectants or antacids

Question 44

Etiology of hepatic encephalopathy

Answer 44

- tryptophan is precursor for false NT | - competition for BBB transporter by branched chain aa

Question 45

Prevention of hepatic encephalopathy

Answer 45

- Plasma: albumin binds tryptophan | - increased branched chain aa and decreased aromatic aa including Tryptophan

Question 46

Tx of hepatic encephalopathy

Answer 46

Lower the pH and ammonia absorption by increasing bacterial fermentation of undigested carbs in LI: - give lactulose +/- neomycin OR: - metronidazole, rifaximin - soluble fiber Absorption: Metronidazole > Neomycin > Rifaximin

Question 47

Tx of ascites

Answer 47

- plasma - salt restriction - spironolactone (aldosterone antagonist) +/- loop diuretic (furosemide) initially only - paracentesis (ONLY for relief of breathing; can dehydrate patient quickly) - abx if culture positive - avoid liquorice-containing chinese meds

Question 48

Summary points

Answer 48

- liver enzymes can decrease over time despite dz progression - bile acids/ammonia don't correlate well with function or signs - Glu/Alb/BUN/PT/bilirubin affected LATE in liver dz - bilirubin delta persists despite clinical improvement

Question 49

Management of liver dz: assessment before tx:

Answer 49

CBC, Chem, UA, function tests, imaging, biopsy