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 & right hepatic ducts form the:
A
common hepatic duct
7
Q
The common hepatic duct is responsible for:
A
draining bile from liver & transports waste from the liver & aids in digestion (by releasing bile)
8
Q
carries bile from the liver & the gallbladder through the pancreas and into the duodenum:
A
common bile duct
9
Q
Where does the common bile duct carry bile (pathway):
A
- Liver
- gallbladder
- pancrease
- duodenum
10
Q
The common bile duct is part of the:
A
biliary duct system
11
Q
The biliary duct system is formed where the:
A
ducts from the liver and gall bladder are joined
12
Q
Where the ducts of the 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 onto the right:
A
hepatic veins
15
Q
Provides oxygen & nutrition to liver tissues:
A
hepatic artery
16
Q
Delivers substance absorbed by the GI tract (stomach, intestines, 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
bound to albumin (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 produces ____ for fat storage
cholesterol
28
Bilirubin levels can escalate from:
1. blood disorders
2. chronic liver disease
3. blockage of bile ducts
4. hepatitis (viral, ETOH, drug - induced)
5. cirrhosis
29
Blood disorders that increase bilirubin 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 prepares ____ for excretion
drugs
34
Responsible for drug conjugation & metabolism:
hepatocytes
35
Types of liver damage:
1. hepatocellular (inflammation & injury)
2. cholestatic (obstructive)
3. mixed
4. cirrhosis (fibrotic, end-stage, acute or chronic)
5. neoplastic
36
Damage to the liver caused by inflammation & injury:
hepatocellular
37
Damage to the liver caused by obstruction:
cholestatic
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: Hepatcellular carcinoma may be an increased risk in patient who have had many viral disease
True
41
Signs of liver disease 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. asterixis
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 & symptoms of liver disease?
mental confusion
44
What can be seen in the following image?
Xanthelasma (cholesterol deposits in the skin- a good indicator that the patient has chronic liver disease)
45
Fatty cholesterol deposits in the skin; a good indicator the patient has some sort of liver disease
Xanthelasma
46
What is seen in the following image?
Spider angioma
47
Capillary fragility seen in the skin, due to lack of clotting factors; increased peripheral endothelial vasculature:
Spider angioma
48
When the liver is not metabolism 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
49
Asterixis is also known as:
flapping tremor
50
What is a classic sign of hepatic encephalopathy (HE)?
Asterixis
51
Describe asterixis:
jerky movements when the hands are extended at wrists
52
What can be seen in the following image?
Asterixis
53
Sign associated with poor ammonium metabolism:
Asterixis
54
A syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in patients with severe liver disease:
Hepatic encephalopathy (HE)
55
HE can be a chronic problem in patients with _____, managed medically to varying degrees of success, punctuated with occasional exacerbations
cirrhosis
56
T/F: Although acute exacerbations of HE are rarely fatal, they are a frequent cause of hospitalization among patients with cirrhosis
True
57
What are some blood tests that can determine general liver function?
1. CBC
2. CMP (comprehensive metabolic panel)
58
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
59
Test that evaluates the cells that circulate in the blood:
CBC
60
What cells are evaluates on a CBC:
1. RBC
2. WBC
3. PLTs
61
A CBC is an indicator of:
overall health
62
A CBC may detect a variety of diseases & conditions including:
1. infection
2. anemia
3. leukemia
4. lymphoma
5. neutropenia
63
CMP:
Comprehensive metabolic panel
64
A CMP may also be called:
chemical screen or SMAC 14 (Sequential multiple analysis- computer)
65
A CMP consists of _____ blood tests which serve as:
14 blood tests; initial broad medical screening tool
66
A CMP includes:
1. general tests
2. kidney function assessment
3. electrolytes
4. proteins tests
5. liver function assessment
67
Why are CMPs (Chemical screen/SMACs) a good general test for the patients overall health?
Because they look at multiple organ systems
68
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. globulin
69
Bilirubin is a product of:
heme breakdown
70
Increased total bilirubin = increased:
severity of liver injury
71
Bilirubin that is insoluble, bound to albumin, not filtered by kidney:
unconjugated (indirect)
72
T/F: with unconjugated bilirubin, increased SERUM is not really indicative of liver disease
True
73
Form of bilirubin that indicates hemolysis, ineffective erythropoiesis (thalassemia, vitamin B deficiency, Gilbert syndrome)
Unconjugated (indirect)
74
T/F: With conjugated bilirubin, increased SERUM levels is NOT really indicative of liver disease
False- this is indicative of liver disease
75
The form of bilirubin that is water-soluble and excreted by the kidney:
Conjugated (direct)
76
All _____ bilirubin is conjugated
URINE
77
A protein involved with bone metabolism that is not specific to liver disease but may indicate cholestatic disease:
alkaline phosphatase (high)
78
This protein is altered in multiple disease condition, but especially bone neoplasms:
Alkaline phosphatases
79
AST, ALT and GGT are all:
transaminases (liver enzymes needed for protein synthesis & specific to liver function)
80
High levels of transaminases (AST, ALT, GGT) indicates:
Damage to hepatocytes from hepatocellular disease
81
T/F: High levels of transaminases (AST, ALT, GGT) are individually proportionally reflective of severity of liver damage
False- NOT individually proportionally reflective
82
What transaminase is more indicative of cholestatic disease (blockage) & alcoholic liver disease?
GGT
83
AST:ALT ratios are more informative; the ____ the ratio, the more specific an indicator of hepatic disease
lower
84
Synthesized exclusively by hepatocytes:
albumin
85
What is the half-life of albumin?
18-20 days
86
Hypoalbuminemia is more indicative of _____ but not specific to ____
chronic liver disease; liver disease
87
Hypoalbuminemia is not specific to liver disease as it is also involved in:
1. malnutrition
2. chronic infection
3. gut disease
88
What are two liver function tests?
1. albumin
2. prothrombin time
89
Prothrombin time measures:
extrinsic & common pathways
90
The liver produces all coagulation factors except:
VIII (vascular endothelial cells)
91
Prothrombin time (PT) measures factors:
1, 2, 5, 7, 10
92
What are the vitamin K dependent coagulation factors?
2, 7, 9, 10
93
INR is actually:
PT-INR
94
What are the four A's that are measures on a CMP?
1. Albumin
2. Alkaline phosphatase
3. ALT
4. AST
95
What is the B that is measured on a CMP?
BUN
96
What are the four C's measured on a CMP?
1. Calcium
2. Chloride
3. CO2
4. Creatinine
97
What is the G that is measured on a CMP?
Glucose
98
What is the P that is measured on a CMP?
Potassium
99
What is the S that is measured on a CMP?
Sodium
100
What are the two T's measured on a CMP?
1. Total bilirubin
2. Total protein
101
All hepatitis viruses are RNA viruses, except for ____ which is an enveloped DNA virus
Hep B (HBV)
102
Where does the hepatocellular damage in hepatitis viruses come from?
host immune response to viral antigens (rather than direct cytopathic effect from virus)
(think of it like an autoimmune disease)
103
List some components of viral hepatitis that cause hepatocellular damage (think about the hosts response)
1. cytotoxic T cells
2. pro inflammatory cytokines
3. natural killer cell response
4. antibody-dependent cellular cytotoxicity
104
Viral hepatitis may be _____ / ____ and also ____ / _____
asymptomatic or symptomatic; acute or chronic
105
Chronic hepatitis may lead to:
1. cirrhosis
2. liver failure
3. hepatocellular carcinoma
106
What is the risk factor for hepatitis leading to hepatocellular carcinoma?
Immunosuppression
107
T/F: A patient with hepatitis can have a chronic infection yet be asymptomatic deeming them in the carrier state (low levels)
True
108
Viral hepatitis is also called _____ and is a ____ pathogen
serum hepatitis; blood-borne
109
Describe the transmission of viral hepatitis:
1. parenteral
2. intimate
3. sexual
110
The Hep B virus can last up to _____ on an infected surface
7 days
111
What is the incubation period of Hep B?
90 days average
112
Describe the chronicity of Hep B:
90% infants
25-50% children (1-5)
<5% of adutls
113
Is there a vaccination for Hep B? If so describe:
Yes- 3 doses (1 initial, 1 month, 6 months)
114
For the Hep B vaccination, seroconversion is necessary, meaning
Your body has to have time to develop specific antibodies as a result of the immunization
115
In the chronic state of Hep B, the _____ is always present in the body
surface antigen
116
What is another name for Hep C:
Cytomegalovirus
117
Dentistry has adopted the ____ against blood-borne diseases which has dramatically decreased the incidence of viral spread
Universal/standard precautions
118
Patients with chronic Hepatitis C must stay on ____ for a long time
Immunosuppression drugs
119
Hepatitis virus where the average prevalence in injection drug users is 53%:
Hep C
120
What population should be screened due to a higher risk of having the hepatitis C virus?
Baby boomers
121
_____ % of untreated Hep C patients are able to clear the virus
15-25
122
Hepatitis C has a high risk for becoming _____ (75-85%)
Chronic
123
10-20% of patients who have chronic hep C develop ______
cirrhosis (takes 20-30 years)
124
Patients who have chronic hep C are at increased of ____ & ____
1. Hepatocellular carcinoma (HCC)
2. Death
125
T/F: HIV has a higher needle stick transmission rate than HCV
False- HCV higher
126
Is there a vaccine for Hep C? If so describe
No
127
What is considered a "cure" for HCV?
Undetectable HCV RNA levels after 12 weeks of recommended protease inhibitor therapy
128
List some examples of the protease inhibitor therapy (immunosuppression drugs) used to treat Hep C:
1. mavyret
2. epclusa
3. harvoni
129
T/F: There are chronic carriers associated with Hep C
True
130
Form of hepatitis that usually presents as a coinfection with hepatitis B:
Hepatitis D (HDV)
131
Compare the severity of Hep B versus Hep B+D:
Hep B+D is more severe than Hep B alone
132
With Hep D, one is at risk for ____ which results in _____
fulminant hepatitis; massive hepatocellular destruction
133
What hepatitis viruse(s) are considered blood-borne?
Hep B, C, D
134
What hepatitis viruse(s) are not blood-borne and are rather fecal-oral borne:
Hep A, E
135
Infectious hepatitis, feca-oral transmission:
Hep A & E
136
Hep A & Hep E are considered highly ____ & ____
contagious & transmissible
137
Is there a vaccine for hep A or E? If so describe:
Yes for Hep A not for Hep E
138
T/F: Most carriers of HBV, HCV & HDV are unaware they have it
True
139
T/F: Hepatitis can be contracted by the dentist from an infected patient
True
140
Chronic, active hepatits patients may have liver dysfunction such as:
1. increased bleeding
2. altered drug metabolism
141
Hep ____ is the most likely viral hepatitis to be transmitted occupationally to a dental healthcare worker, followed by Hep ____
B; C
142
T/F: Little to no risk exists for transmission of Hep A, Hep E & non-A-E hepatitis viruses
True
143
When we consider ALL patients infectious:
Universal precautions
144
If active disease status, a risk for dental care in a patient with hepatitis virus is:
They likely are not making the blood clotting factors
145
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 risks
-consider referral to specialized center
-isolation may be necessary
146
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
147
How would you respond to the following situation:
Needlestick
1. consult the physician
2. consider hepatitis B immunoglobulin
148
What are some viral hepatitis oral manifestations?
1. bleeding
2. mucosal jaundice
3. glossitis
4. angular cheilosis
149
What is an oral manifestation we may see in a patient who has chronic HCV?
1. Oral lichen planus
2. lymphocytic sialodenitis (Sjogren-like syndrome)
150
An oral manifestation of Hepatitis viruses that is really 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
151
Viral hepatitis oral manifestation in which the patient has enlarged parotid glands (Sjogren-like syndrome). What is this due to?
Lymphocytic sailadenitis; due to lymphocytic infiltration & edema of the parotid glands
152
Type of hepatitis in which there is no virus inducing the response:
autoimmune hepatitis
153
What is the cause of autoimmune hepatitis?
Idiopathic
154
Autoimmune hepatitis is more severe in:
children
155
What is one of the main contributors to drug-induced liver disease?
alcohol
156
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
157
Degeneration of the liver caused by atrophy of hepatitis resulting; where scarring & connective tissue take over the liver:
Non-alcoholic fatty liver disease (form of cirrhosis not caused by drugs or alcohol)
158
Alcohol as well as its metabolite are:
hepatotoxic
159
Alcohol causes _____ which compounds the liver damage
inflammation
160
It typically takes ____ years of excessive alcohol intake to develop alcoholic liver disease
10
161
What is the first stage of alcoholic liver disease? Describe
Patients first develop fatty liver disease; reversible
162
When has developed fatty liver disease from alcohol & continues to use alcohol, this can lead to:
irreversible changes & necrosis (due to persistent inflammation)
163
Once a patient has reach the stage of irreversible changes & necrosis of liver due to alcohol use and continues alcohol use, eventually ____ & ____ develop which is irreversible and leads to _____
fibrosis; cirrhosis; hepatic failure
164
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
165
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
166
Describe ascites:
hepatorenal syndrome (beer belly appearance)
167
Describe esophageal varies:
GI bleed
168
Describe hepatospenomegaly:
1. Enlarged spleen due to portal hypertension
2. decreased platelet function
3. leads to thrombocytopenia
169
Describe coagulation disorders associated cirrhosis (alcohol induced):
1. decreased synthesis of clotting factors
2. impaired clearance of anticoagulants
3. decreased vitamin K absorption
170
Vitamin K absorption requires:
biliary excretion
171
Describe the anemia that is a complication of cirrhosis (alcohol induced):
1. iron deficiency
2. macrocytosis
172
Describe the encephalopathy that is a complication of cirrhosis (alcohol induced):
neurotoxins not removed from the liver
173
How might you identify a patients alcoholism?
1. history
2. clinical examination
3. detection of odor on breath
4. suspicious behavior
5. information from family/friend
174
What is the best way to identify a patients alcoholism?
history
175
What is problem for the dentist, with a patient who has early on/mild liver dysfunction caused by alcohol?
Liver enzyme infection may increase metabolism of prescribed drugs, limiting their effect
176
What is problem for the dentist, with a patient who has severe liver dysfunction caused by alcohol?
Drug metabolism may conversely be hindered & drug toxicity is a concern
177
In many chronic liver disease the ratio of AST:ALT is ______ whereas in alcoholics the ratio is much _____
lower; higher
178
What is the AST: ALT ratio in a patient with alcoholisn?
Greater than or equal to 2
179
A patients presents with an AST: ALT ratio of 2.4 and an elevated GGT, what might you suspect?
Alcoholic liver disease
180
Total protein-
Hepatitis:
Cirrhosis:
Hepatitis: normal
Cirrhosis: decreased
181
Albumin-
Hepatitis:
Cirrhosis:
Hepatitis: normal
Cirrhosis: decreased
182
Globulin-
Hepatitis:
Cirrhosis:
Hepatitis: normal
Cirrhosis: increased
183
A/G Ratio-
Hepatitis:
Cirrhosis:
Hepatitis: greater than 1
Cirrhosis: less than 1
184
Alkaline phosphatase-
Hepatitis:
Cirrhosis:
Hepatitis: elevated 1-2x normal
Cirrhosis: elevated 1-2x normal
185
ALT-
Hepatitis:
Cirrhosis:
Hepatitis: vlaues increase into the thousands
Cirrhosis: ALT & AST are increased up to a maximum of 300 IU
186
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
187
In cirrhosis ____> ___
AST > ALT
188
In hepatitis ____ > _____
ALT > AST
189
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
190
A patient with jaundice tissues and a breath that is ____ & ____ is associated with liver failure
sweet & musty
191
Alcohol abuse is a STRONGG risk factor for:
oral squamous cell carcinoma
192
_____ is the number one abused drug in terms of ER visits, hospital admission, family violence & social problems
alcohol abuse
193
Laboratory tests may be needed to evaluate the fitness of the patient for dental treatment, if we suspect liver disease, what labs tests may we order?
1. CBC with differential (this includes platelets)
2. Liver function tests which includes:
-AST
-ALT
-GGT
-Albumin
-Alkaline phosphatase
-Bilirubin
194
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 done one tooth at a time rather than an entire quadrant
195
In a patient with significant liver disease what should you avoid post-operatively?
NO NSAIDs for pain management
196
In a patient with significant liver disease what can you recommend post-operatively for pain control?
Acetaminophen up to 2g daily in most cases
197
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 functions
Both statements true
198
For patients with liver disease, you should minimize use of drugs metabolized by the liver, these drugs include:
1. local anesthetic
2. analgesics
3. sedatives
4. antimicrobials
199
What is a concern with local anesthetics in patients with liver disease?
Local anesthetics are not metabolized by the liver and may result in encephalopathy
200
What may be a better option as opposed to amine anesthetics in a patient with liver disease?
Ester anesthetics (but can be hard to find & not as long lasting pain control)
201
Opioids can be used in necessary for post-op pain control in a liver disease patient. Which ones would we avoid and which could we prescribe?
AVOID: Hydrocodone & Oxycodone
PRESCRIBE: Hydromorphone
202
What sedatives should be avoided in a person with liver disease? Which ones are acceptable?
AVOID: Benzodiazepines
Potentially use: Lorazepam (due to its shortened half-life)
N2O is a safer option if possible
203
What antimicrobials should be avoided in a person with liver disease? Which ones are acceptable?
AVOID: Metronidazole, Tetracycline, Doxycycline, Fluconazole- these get broken down in liver
Possible issue with: Clindamycin
204
Disulfram affect:
antimicrobial alcoholics take to make them violently ill with alcohol
205
Type of hypertension that is a complication of cirrhosis:
Portal hypertension
206
What is significantly elevated with portal hypertension?
BP
207
With portal hypertension _____ should be limited as well as no use of retraction cord with ____
Epi, Epi
208
Why do we see thrombocytopenia with portal hypertension?
Due to platelet sequestration in the spleen
209
What risk ratio should we weigh when deciding to prescribe antibiotics prophylactically?
Impairment of drug metabolism vs. immune impairment
210
T/F: Antibiotic prophylaxis is a consideration for patient with liver disease
True
211
