Lecture 3- Hepatic Disease Flashcards
1
Q
Where is the liver located?
A
upper right quadrant
2
Q
Largest internal organ:
A
liver
3
Q
Describe the blood supply to the liver:
A
Dual supply
~20% hepatic artery
~80% portal vein
4
Q
The hepatic artery delivers:
A
oxygenated blood
5
Q
The portal vein delivers:
A
nutrients
6
Q
Left and right hepatic ducts form the:
A
common hepatic duct
7
Q
The common hepatic duct is responsible for:
A
draining bile from liver and transports wastes from the liver and aids in digestion (by releasing bile)
8
Q
Carries bile from the liver and the gallbladder thorough the pancreas and into the duodenum:
A
Common bile duct
9
Q
Where does the common bile duct carry bile? (pathway)
A
- liver
- gallbladder
- pancreas
- duodenum
10
Q
The common bile duct is part of the:
A
biliary duct system
11
Q
The biliary duct system is formed where:
A
the ducts from the liver and gallbladder are joined
12
Q
Where the ducts and liver and gallbladder join:
A
biliary duct system (common bile duct is part of this)
13
Q
the hepatic portal vein goes from the ___ to the ___
A
GI system to the liver
14
Q
Drains venous blood from liver to inferior vena cava and on to the right:
A
hepatic veins
15
Q
Provides oxygen and nutrition to liver tissues:
A
hepatic artery
16
Q
Delivers substances absorbed by the GI tract (stomach, intestine, spleen, & pancreas) for metabolic conversion and/or removal in the liver:
A
hepatic portal vein
17
Q
Cells of the liver=
A
hepatocytes
18
Q
What is the function of the hepatocytes?
A
synthesize proteins
19
Q
Hepatocytes are responsible for synthesizing proteins such as:
A
- immunoglobulins
- albumin
- coagulation factors
- carrier proteins
- growth factors
- hormones
20
Q
In addition to synthesizing proteins, hepatocytes also synthesize:
A
bilirubin
21
Q
Made from the breakdown of RBCs:
A
bilirubin
22
Q
How is bilirubin transported to the liver?
A
by being bound to albumin in its unconjugated form
23
Q
considered the unconjugated form of bilirubin:
A
bilirubin bound to albumin
24
Q
The liver conjugates bilirubin by unbinding the protein (albumin) & binding it to ____
A
glucose
25
Bilirubin + albumin =
Bilirubin + glucose =
UNconjugated form
conjugated form
26
The hepatocytes produce bile for:
digestion
27
The hepatocytes produce ____ for fat storage
cholesterol
28
Bilirubin levels can escalate from:
1. blood disorders
2. chronic liver disease
3. blockage of bile ducts
4. Hepatitis (etoH, viral, drug induced)
5. cirrhosis
29
Blood disorders that increase bilirubin levels include:
1. hemolytic anemia
2. sickle cell anemia
3. inadequate transfusions
30
Increased bilirubin results in:
1. jaundice
2. fatigue
3. cutaneous itch
4. discolored urine
5. discolored feces
31
A function of hepatocytes is to regulate ____.
nutrients
32
Which nutrients are the hepatocytes responsible for regulating?
1. glucose
2. glycogen
3. lipids
4. amino acids
33
Hepatocytes prepare ___ for excretion
drugs
34
Responsible for drug conjugation and metabolism:
hepatocytes
35
Types of liver damage include:
1. hepatocellular (infiammation and injury)
2. cholestatic (obstructive)
3. mixed
4. cirrhosis (fibrotic, end-stage), acute or crhonic
5. neoplastic
36
Damage of the liver caused by inflammation & injury:
hepatocellular
37
Damage to the liver caused by obstruction:
cholesstatic
38
Fibrotic or end-stage liver damage that may be acute or chronic:
cirrhosis
39
Scarring of the liver in which you start losing hepatocytes:
cirrhosis
40
T/F: Hepatocellular carcinoma may be an increased risk in patients who have had many viral diseases
true
41
Signs of liver diseases include:
1. jaundice
2. ascites
3. edema
4. GI bleed
5. dark urine
6. light stool
7. mental confusion
8. xanthelasma
9. spider angiomas
10. palmar erythema
11. asaterixis
12. hyperpigmentation
42
Symptoms of liver disease include:
1. appetite loss
2. bloating
3. nausea
4. RUQ pain
5. fatigue
6. mental confusion
43
What is both a sign and symptoms of liver disease?
mental confusion
44
What is seen in the following image?
45
Fatty cholesterol deposits in the skin that is a good indicator the patient has some sort of liver disease
xanthelasma
45
What is seen in the following image?
spider angiomas
46
Capillary fragility seen in the skin due to lack of clotting factors; increased peripheral endothelial vasculature:
spider angiomas
47
When liver is not metabolizing ammonia from the body, (usually converts ammonia to ammonium so it can be excreted), the ammonia builds up, getting to the brain and causes:
asterixis
48
Asterixis is also known as:
flapping tremor
49
What is a classic sing of hepatic encephalopathy (HE)
asterixis
50
Described asterixis:
jerky movements when the hands are extended at wrists
51
What can be seen in the following image?
asterixis
52
Sign associated with poor ammonium metabolism:
Asterixis
53
A syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in patient with severe liver disease:
Hepatic encephalopathy (HE)
54
HE can be a chronic problem in patients with ___, managed medically to varying degrees of success, punctuated with occasion exacerbations
cirrhosis
55
T/F: Although acute exacerbations of HE are rarely fatal, they are a frequent cause of hospitalizations among patients with cirrhosis
True
56
What are some blood test that determine general liver function:
1. CBC
2. CMP (comprehensive metabolic panel)
57
List some SPECIFIC liver function tests:
1. lipid panel
2. VDRL
3. PSA (prostate specific antigen)
4. SARS antigen & antibody
5. HIV
6. HEP B
7. Bleeding times
58
Test that evaluates the cells that circulate in the blood:
CBC
59
What cells are evaluated on a CBC?
1. RBCs
2. WBCs
3. PLTs
60
A CBC is an indicator of:
overall health
61
A CBC may detect a variety of diseases and conditions including:
1. infection
2. anemia
3. leukemia
4. lymphoma
5. neutropenia
62
CMP:
Comprehensive metabolic panel
63
A CMP may also be called:
chemical screen or SMAC 14 (sequential multiple analysis - computer)
64
A CMP consists of ___ blood tests which serve as:
14 blood tests; initial broad medical screening tool
65
A CMP includes:
1. general tests
2. kidney function assessment
3. electrolytes
4. protein tests
5. liver function assessment
66
Why are CMPs (chemical screen/SMACs) a good general test for the patients overall health?
Because they look at multiple organ systems
67
In terms of assessing liver function, the following proteins are good indicators of liver health:
1. bilirubin
2. alkaline phosphatase (ALP)
3. Transaminases
4. albumin
5. globlulin
68
Bilirubin is a product of:
heme breakdown
69
Increased total bilirubin = increased:
severity of liver injury
70
bilirubin that is insoluble, bound to albumin, not filtered by kidney:
unconjugated (indirect)
71
T/F: With unconjugated bilirubin, increased SERUM is not really indicative or liver disease
True
72
Form of bilirubin that indicates hemolysis, ineffective erythropoiesis (thalassemia, vitamin B deficiency, Gilbert syndrome)
unconjugated (indirect)
73
T/F: With conjugated bilirubin, increased SERUM levels is NOT really indicative of liver disease
False- this is indicative of liver disease
74
The form of bilirubin that is water soluble and excreted by the kidney:
conjugated (direct)
75
All ____ bilirubin is conjugated
urine
76
A protein involved with bone metabolism that is not specific to liver disease but may indicate cholestatic disease
Alkaline phosphatase (high)
77
This protein is altered in multiple disease conditions, but especially bone neoplasms:
alkaline phosphatases
78
AST, ALT, and GGT are all:
transaminases (liver enzymes) needed for protein synthesis & specific to liver function
79
High levels of transaminases (AST, ALT, GGT) indicates:
damage to hepatocytes from hepatocellular disease
80
T/F: High levels of transaminases (AST, ALT, GGT) are individually proportionally reflective of severity of liver damage
False- not individually proportionally reflective
81
What transaminase is more indicative of cholestatic disease (blockage) and alcoholic liver disease?
GGT
82
AST: ALT ratios are more informative; the ____ the ratio, there specific an indicator of hepatic disease
lower
83
Synthesized exclusively by hepatocytes:
Albumin
84
What is the half life of albumin?
18-20 days
85
Hypoalbuminemia is more indicative of ____ but not specific to ____
chronic liver disease; liver disease
86
Hypoalbuminemia is not specific to liver disease as it is also involved in:
1. malnutrition
2. chronic infection
3. gut disease
87
What are two liver function tests?
1. albumin
2. prothrombin time
88
The prothrombin time test measures;
extrinsic & common pathway
89
The liver produces all coagulation factors except for:
VIII (vascular endothelial cells)
90
PT measures factors:
1, 2, 5, 7, 10
91
What are the vitamin K dependent coagulation factors?
2, 7, 9,10
92
INR is actually
PT INR
93
What are the 4 A's that are measured on a CMP?
1. albumin
2. alkaline phosphatase
3. ALT
4. AST
94
What is the B that is measured on a CMP?
BUN
95
What are the 4 C's that are measured on a CMP?
1. calcium
2. chloride
3. CO2
4. creatinine
96
What is the G measured on a CMP?
Glucose
97
What is the P measured on a CMP?
Potassium
98
What is the S that is measured on a CMP?
Sodium
99
What are the two Ts measured on a CMP?
1. Total bilirubin
2. Total protein
100
All hepatitis viruses are RNA viruses except for ____ which is an enveloped DNA virus
Hep B (HBV)
101
Where does the hepatocellular damage from hepatitis viruses come from?
host immune response to viral antigens (rather than direct cytopathic effect from virus)
(think of this like an autoimmune disease)
102
List some components of viral hepatitis that cause hepatocellular damage: (think about the host response)
1. cytotoxic T-cells
2. Proinflammatory cytokines
3. NK cell response
4. Antibody-dependent cellular cytotoxicity
103
Viral hepatitis infection may be ___ /___ and ___/___
asymptomatic or symptomatic; acute or chronic
104
Chronic hepatitis can lead to:
1. cirrhosis
2. liver failure
3. hepatocellular carcinoma
105
What is the risk factor for hepatitis leading to hepatocellular carcinoma?
immunosuppression
106
T/F: A patient with hepatitis can have a chronic infection yet be asymptomatic deeming them in the carrier state (low levels)
true
107
Viral hepatitis is also called _____, and is a ____ pathogen
serum hepatitis; blood-borne
108
Describe the transmission of viral hepatitis:
1. parenteral
2. intimate
3. sexual
109
The hep B virus can last up to ___ on an infected surface
7 days
110
What is the incubation period for Hep B?
90 days average
111
Describe the chronicity of Hep B:
- 90% infants
- 25-50% 1-5
- Less than 5% adults
112
Is there a vaccination for hep B? If so describe
Yes- 3 doses (1 initial, 1 month, 6 months)
113
For the Hep B vaccination, seroconversion is necessary meaning:
your body has to have time to develop specific antibodies as a result of immunization
114
In the chronic state of Hep B, the ___ is always present in the body
surface antigen
115
What is another name for hep C?
cytomegalovirus
116
Dentistry has adopted the ___ against blood borne diseases which has dramatically decreased the incidence of viral spread
universal/standard precautions
117
Patients with chronic hep C must stay on ___ for a long time
immunosuppression drugs
118
Hepatitis virus where the average prevalence in injection drug users is 53%
Hep C
119
What population should be screened due to a higher risk of having the hep C virus?
baby boomers
120
___% of untreated hep C patients are able to clear the virus
15-25%
121
Hep C has a high risk for becoming ____ (75-85%)
chronic
122
10-20% of patients who have chronic hep C develop:
cirrhosis (takes 20-30 years)
123
Patients who have chronic hep C are at an increased risk for: (2)
1. hepatocellular carcinoma (HCC)
2. death
124
T/F: HIV has a higher needle stick transmission rate than HCV
False- HCV higher
125
Is there a vaccine for Hep C? If so describe
No
126
What is considered a "cure" for HCV?
undetectable HCV RNA levels after 12 weeks of recommended protease inhibitor therapy
127
List some examples of the protease inhibitor therapy (immunosuppression drugs) used to treat hep C:
1. Mavyret
2. Epclusa
3. Harvoni
128
T/F: There are chronic carriers associated with hep C
True
129
Form of hepatitis that usually presents coinfection with Hep B:
Hep D (HDV)
130
Compare the severity of Hep B versus Hep B+D
Hep B+D is more severe than Hep B alone
131
With Hep D, one is at risk for ____ which results in:
fulminant hepatits; massive hepatocellular destruction
132
What hepatitis viruses are considered blood borne?
Hep B, C, D
133
What hepatitis viruses are considered fecal-oral borne?
Hep A & Hep E
134
Infectious hepatitis, fecal-oral transmission:
Hep A & E
135
Hep A and Hep E are considered highly ___ & ___
contagious and transmissable
136
Is there a vaccine for Hep A or Hep E? If so describe:
Yes for hep A; not for hep E
137
T/F: Most carries of HBV, HCV, and HDV are unaware they have hepatitis
True
138
T/F: Hepatitis can be contracted by the dentist from an infected patient
True
139
Chronic, active hepatitis patients may have chronic liver dysfunction such as:
1. increased bleeding
2. altered drug metabolism
140
Hep ___ is the most likely viral hepatitis to be transmitted occupationally to a dental health care worker followed by Hep ___.
Hep B; Hep C
141
T/F: There is little to no risk exists for transmission, for HAV, HEV, and non-A-E hepatitis viruses
True
142
When we consider ALL patients infectious:
Universal precautions
143
If active hep disease status, a risk for dental care in patients with hep virus is:
they likely are not making the blood clotting factors
144
How would you respond to the following situation?
Patients with ACTIVE hepatitis (acute or chronic)
1. defer all elective dental treatment
2. if emergency treatment
- consult physician
- determine severity of disease
- determine dental treatment risk
- consider referral to specialized center
- isolation may be necessary
145
How would you respond to the following situation?
Patients with history of hepatitis (resolved, chronic inactive)
1. consider risk factors
2. consult physician to determine liver status
146
How would you respond to the following situation?
Needle stick
1. consult the physician
2. consider hepatitis B immunoglobulin
147
What are some viral hepatitis oral manifestations?
1. bleeding
2. mucosal jaundice
3. glossitis
4. angular cheilosis
148
What is an oral manifestation we may see in a patient with chronic HCV?
1. oral lichen Plans
2. lymphocytic sialadenitis
149
An oral manifestation of hepatitis viruses that is usually part of the immune suppression from the lack of production of immunoglobulins that presents clinically as a fungal or bacterial infection at the corners of the mouth:
angular cheilosis
150
Viral hepatitis oral manifestation in which the patient has enlarged parotid glands (Sjogren-like syndrome). What is this due to?
Lymphocytic sialodenitis; lymphocytic infiltration and edema in the parotid glands
151
Type of hepatitis in which there is no virus inducing the response:
autoimmune hepatitis
152
What is the cause of autoimmune hepatitis?
Idiopathic
153
Autoimmune hepatitis is more severe in what population?
children
154
What is one of the main contributors to drug induced liver disease?
alcohol
155
List some mechanisms that result in drug-induced liver disease?
1. DIRECT toxicity to hepatocytes
2. Production of hepatotoxic metabolites
3. Accumulation of drug due to altered metabolism
156
Degeneration of the liver caused by atrophy of hepatocytes; where scarring and connective take over the liver:
Non-alcoholic fatty liver disease (not caused by drugs or alcohol)
157
alcohol and its metabolite are :
hepatotoxic
158
alcohol causes ____ which compounds the liver damage
inflammation
159
It typically takes ___ of excessive alcohol intake to develop alcoholic liver disease
10 years
160
What is the first stage of alcoholic liver disease? Describe
Patients first develop fatty liver disease; reversible
161
When a patient has developed fatty liver disease from alcohol and continues alcohol use, this can lead to:
irreversible changes & necrosis (due to persistent inflammation)
162
Once a patient has reached the stage of irreversible changes and necrosis of the liver due to alcohol use and continues alcohol use, eventually ____ & ____ develop which is irreversible and leads to ____.
fibrosis & cirrhosis; hepatic failure
163
Complications of alcoholic liver disease include:
1. bleeding tendencies
2. unpredictable drug metabolism
3. impaired immune function
4. peripheral neuropathies
5. dementia & psychosis
6. anorexia
164
Complications of cirrhosis (due to alcohol) include:
1. ascites
2. esophageal varices
3. jaundice
4. hepatosplenomegaly
5. coagulation disorders
6. hypoalbuminemia
7. anemia
8. neutropenia
9. encephalopathy
165
Describe ascites:
hepatorenal syndrome (beer belly appearance)
166
Describe esophageal varices:
GI bleed
167
Describe hepatosplenomegaly:
1. enlarged spleen due to portal hypertension
2. decreased platelet function
3. leads to thrombocytopenia
168
Describe the coagulation disorders associated with cirrhosis (alcohol induced)
1. decreased synthesis of clotting factors
2. impaired clearance of anticoagulations
3. decreased vitamin K absorption
169
VItamin K absorption requires:
biliary excretion
170
Describe the anemia that is a complication of cirrhosis (alcohol induced):
1. iron deficiency
2. macrocytosis
171
Describe encephalopathy that is a complication of cirrhosis (alcohol induced):
Neurotoxins not removed from the liver
172
How might you identify a patients alcoholism?
1. history
2. clinical examination
3. detection of odor on breath
4. suspicious behavior
5. info from family/friend
173
What is the BEST way to identify a patients alcoholism?
history
174
What is a problem for the dentist with a patient who has early on/mild liver dysfunction caused by alcohol?
Liver enzyme induction may increase metabolism of prescribe drugs, limiting their effect
175
What is a problem for the dentist with a patient who has early on/mild liver dysfunction caused by alcohol?
Drug metabolism may conversely be hindered and drug toxicity is a concern
176
In many chronic liver diseases, the ratio of AST: ALT is ___ where as in alcoholics the ratio of AST: ALT is much _____
low; higher
177
What is the AST: ALT ratio in a patient with alcoholism?
Greater than or equal to 2
178
A patient presents with AST: ALT ratio of 2.4 and an elevated GGT. What might you suspect?
alcoholic liver disease
179
Total protein-
Hepatitis:
Cirrhosis:
Hepatitis: Normal
Cirrhosis: Decreased
180
Albumin-
Hepatitis:
Cirrhosis:
Hepatitis: Normal
Cirrhosis: Decreased
181
Globulin-
Hepatitis:
Cirrhosis:
Hepatitis: Normal
Cirrhosis: Increased
182
A/G Ratio
Hepatitis:
Cirrhosis:
Hepatitis: greater than 1
Cirrhosis: Less than 1
183
Alkaline phosphatase-
Hepatitis:
Cirrhosis:
Hepatitis: elevated 1-2 times normal
Cirrhosis: elevated 1-2 times normal
184
ALT-
Hepatitis:
Cirrhosis:
Hepatitis: Values increased into the thousands
Cirrhosis: ALT, AST are increase up to a maximum of 300 IU
185
AST-
Hepatitis:
Cirrhosis:
Hepatitis: values increased to the thousands but ALT is ALWAYS greater than AST
Cirrhosis: NEVER greater than 300 IU AST is always greater than ALT
186
Alcoholic liver disease oral manifestations include:
1. neglect
2. bleeding
3. ecchymoses
4. petechiae
5. glossitis
6. angular cheilosis
7. alcohol odor
8. parotid enlargement
9. xerostomia
187
A patient with jaundice mucosal tissues and a breath that is ___ & ___ is associated with liver failure
sweet & musty
188
Alcohol is a STRONG risk factor for:
oral squamous carcinoma
189
_____ is the number one abused drug in terms of ER visits, hospital admission, family violence and social problems
alcohol abuse
190
Laboratory tests may be needed to evaluate the fitness of the patient for dental treatment(s). If we suspect liver disease, what lab tests may we order?
1. CBC with differential (this includes platelets)
2. Liver function test which includes
- AST
- ALT
- GGT
- Albumin
- Alkaline phosphatase
- Bilirubin
191
T/F: In a patient with significant liver disease SRP should be done one quadrant at a time, not the full mouth.
False- SRP should be one tooth at a time rather an entire quadrant
192
In a patient with significant liver disease, what should you avoid post-op?
NO NSAIDS for pain management
193
In a patient with significant liver disease, what CAN you recommend post-op for pain control?
acetaminophen up to 2g daily
194
T/F: Antibiotic prophylaxis prior to dental procedures is NOT required if no oral infection is present in a patient with liver disease. Patients with SEVERE LIVER DISEASE may need antibiotic prophylaxis for invasive/surgical procedures due to decreased immune function.
Both statements true
195
For patients with liver disease, you should minimize use of drugs metabolized by the liver. These drugs include:
1. local anesthetic
2. analgesics
3. sedative
4. antimicrobials
196
What is a concern with local anesthetics in patients with liver disease?
Local anesthetics are not metabolized properly by the liver and may result in encephalopathy
197
What may be a better option as opposed to amide anesthetics in a patient with liver disease?
Ester anesthetics (but can be hard to find & not as long last for pain control)
198
Opioids can be used if necessary for post-op pain control in a liver diseased person. Which ones would we avoid? Which should we prescribe?
AVOID: hydrocodone & oxycodone
PRESCRIBE: Hydromorphone
199
What sedatives should be avoided in a person with liver disease? Which are acceptable?
AVOID: benzodiazepines
Potentially use: Lorazepam due to its shortened half life
N2O is a safer option if possible
200
What antimicrobials should be avoided in a person with liver disease? Which are acceptable?
AVOID: Metronidazole, Tetracycline, Doxycycline, Fluconazole -- these get broken down in liver
Possible issue with: Clindamycin
201
Disulfiram effect:
antimicrobial alcohols take to make them violently ill with alcohol
202
Type of hypertension that is a complication with cirrhosis:
portal hypertension
203
What is significantly elevated with portal hypertension?
BP
204
With portal hypertension, ___ should be limited as well as no use of retraction cord with ____.
Epi; Epi
205
Why do we see thrombocytopenia with portal hypertension?
due to platelet sequestration in the spleen
206
What risk ratio should we weigh when deciding to prescribe antibiotics prophylactically
impairment of drug metabolism vs. immune impairment
207
T/F: Antibiotic prophylaxis is a consideration in a patient with liver disease
True
208
