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Liver Flashcards

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1
Q

What is a kupffer cell?

A

A type of reticuloendothelial cell responsible for removing bacteria and viruses that enter the liver from the intestine.

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2
Q

What is the largest internal organ?

A

Liver

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3
Q

What is the hepatic acinus?

A

3 zones of hepatic tissue that corresponds with the distance from arterial oxygen (aka portal triad)

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4
Q

What is zone 1 of the hepatic acinus?

A

Most oxygenated

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5
Q

What is zone 2 of the hepatic acinus?

A

Moderately oxygenated

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6
Q

What is zone 3 of to hepatic acinus?

A

Least oxygenated part ~ mostly susceptible to injury

(Also has the highest concentration of CYP 450 enzymes)

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7
Q

What controls the flow of bile released from the common hepatic duct?

A

Sphincter of Oddi

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8
Q

What contacts the sphincter of Oddi?

A

Opioids

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9
Q

What are the 4 fat soluble vitamins that bike helps absorb?

A

DAKE

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10
Q

What does the hepatic artery provide in the liver?

A

25% of the liver blood flow

BUT

50% of the oxygen content

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11
Q

What does the portal vein provide in the liver?

A

75% of the liver blood supply

BUT

50% of the oxygen content

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12
Q

What % of CO does the liver receive?

A

30%

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13
Q

What is a normal pressure in the portal vein?

A

7-10 mmHg

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14
Q

What pressure in the portal vein is diagnostic for portal HTN?

A

> 20-30 mmHg

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15
Q

If there is a reduction in portal vein blood flow, what is the compensatory response?

A

Increasing flow through the hepatic artery

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16
Q

Vitamin K absorption is dependent on what in the gut?

A

Bile in the gut

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17
Q

Where is factor 8 produced?

A

In the liver by SINUSOIDAL cells NOT hepatocytes

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18
Q

What are the ONLY coagulation proteins the liver does not produce?

A

Von Willebrand factor
Factor 3 (tissue factor)
Factor 4 (calcium)

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19
Q

The liver produces all the plasma proteins except what?

A

Immunoglobulins (gamma globulins)

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20
Q

What is albumin a reservoir for?

A

Acidic drugs

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21
Q

What is alpha-1 glycoprotein a reservoir for?

A

Basic drugs!

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22
Q

What does the liver do in a state of hyperglycemia?

A

Glycogenesis > glucose to storage

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23
Q

What does the liver do in a state of hypoglycemia?

A

Glycogenolysis > storage to glucose

Gluconeogenesis > non- carbohydrate to glucose

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24
Q

What happens when the liver is unable to clear ammonia?

A

Hepatic encephalopathy

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25
What causes ammonia in the liver?
De-animation of amino acids
26
What is the process of bilirubin?
In the spleen: hemoglobin > heme > unconjugated bilirubin > attaches to albumin In the liver > conjugates bilirubin with glucuronic acid > increase water solubility > excretion into the bile
27
What are the liver function tests that determine synthetic function?
PT (very sensitive and specific) Albumin (not sensitive)
28
What are the liver function tests that determine hepatocellular injury?
AST ALT (Ranges are 10-40ish)
29
What is the liver function test that determines hepatic clearance?
Bilirubin (0-11)
30
What is the liver function test for biliary duct obstruction?
Alkaline phosphatase 5’-nucleotidase (most specific to biliary duct obstruction)
31
What labs does prehepatic injury affect?
Bilirubin (unconjugated) Cause: hematoma reabsorption
32
What labs does hepatocellular injury affect!
Bilirubin (conjugated) AST ALT PT Causes: cirrhosis, ETOH, drugs, viral infection, sepsis, hypoxemia (Maybe albumin, but only if chronic) Maybe alkaline phosphatase
33
How does post hepatic or cholestatic injury affect liver lab values?
Increases alkaline phosphatase 5’nucleotidase Bilirubin (conjugated) Causes: biliary tract obstruction/sepsis ***it does also affect AST, ALT, and PT, BUT this is late late disease
34
what is the most common cause of chronic hepatitis?
ETOH
35
Which two hepatitises (out of the 4) cause cirrhosis and hepatocellular carcinoma?
Hep B Hep C
36
What is the hepatitis with the highest incidence?
Hep A A > B > C > D
37
What are the three main drugs involved in drug-induced hepatitis?
Acetaminophen Halothane Alcohol
38
What is the max dose of acetaminophen?
4 g/ day
39
What is the most common cause of acute liver failure?
Acetaminophen overdose
40
What is the treatment for acetaminophen overdose?
N-acetylcysteine
41
What is normally conjugated with acetaminophen’s toxic metabolite but is consumed during overdose?
Glutathione
42
What does the liver metabolize Des, Iso, and halothane into?
Inorganic fluoride ions and trifluoroacetic acid (TFA) (TFA ~ terrible for Aliver)
43
What is the second most common cause of chronic hepatitis?
Hep C
44
How does alcohol impair liver function?
Impairs fatty metabolism which causes fat accumulation in the liver
45
What inhaled anesthetics should you use for someone with acute hepatitis?
Iso or sevo
46
What are some hepatotoxic drugs you should avoid in someone with hepatitis?
Acetaminophen Halothane Amiodarone Abx: tetracycline, PCN, Sulfa
47
How does the hepatitis affect Pseudocholinesterase activity?
Decreases it > this may increase DOA for Sux and ester local anesthetics
48
How is MAC affected in the acutely drunk? What about chronic?
Acute : decreased MAC Chronic: increased
49
What vitamin are alcoholics deficient in?
B1 (thiamine)
50
What is Wernicke-Korsakoff syndrome?
Loss of neurons in the cerebellum due to thiamine (B1) deficiency
51
What is the treatment for early alcohol withdrawal syndrome?
Alcohol Beta-blockers Alpha 2 agonists
52
What is cirrhosis?
Characterized by cell death ~ the hepatic tissue is replaced by nodules and fibrotic tissue ***this reduces the number of functional hepatocytes ~ this affects the liver’s ability to perform!
53
How does cirrhosis affect the vascular system of the liver?
Nodules/scar tissue block regular blood vessels > reduces the number of functioning vessels > increases resistance > portal hypertension
54
What happens to blood flow when portal hypertension is prominent?
Body creates collateral vessels that bypass the liver; call portisystemic shunts
55
A Child-Pugh score of what shows an increased risk of perioperative morbidity?
Score of C
56
A MELD score of what shows an increased risk of perioperative morbidity and mortality?
> 15
57
What three factors does the MELD score evaluate?
Bilirubin INR Serum creatinine (MELD that “BIS” on the head)
58
What 5 factors does the Child-Pugh score evaluate?
Albumin PT Encephalopathy Ascites Bilirubin Sassy child “I’m here with BAE and PA”
59
How does end stage liver disease affect the cardio system?
Portosystemic shunt > vasodilation > reciprocal increase CO RAAS activation Increase in shunting > increase SvO2 (not using O2) Diastolic dysfunction
60
How does end stage liver affect portal HTN?
Increase vascular resistance >back pressure in proximal organs > esophageal varies/splenomegaly
61
How does end stage liver disease affect ascites?
Decreased oncotic pressure (no proteins) > increased volume distribution > hypovolemia
62
How does end stage liver dx affect the resp system?
Ascites > decreased compliance and atelectasis Hypoxemia > hyperventilation to compensate Pulmonary vasodilation > shunting PAP> 25 mmHg
63
How does end stage liver dx affect the CNS?
Decreased clearance > increased ammonia > cerebral edema > increased ICP
64
How does end stage liver disease affect autonomic system?
Increased SNS and RAAS
65
How does end stage renal disease affect renal?
Decrease in GFR > RAAS > Na and H2O retention Decrease in GFR > renal failure
66
What is the definite treatment in hepatorenal syndrome?
Liver transplant
67
How does end stage liver disease affect hematologic systems?
Decreased Procoagulants, decreased anticoagulants > bleeding or clot Thrombopoietin and bone marrow depression > decreased platelet production
68
What is the TIPS procedure?
Transjugular intrahepatic portosystemic shunt > bypasses a portion of the hepatic circulation by shunting blood from the portal vein to hepatic vein *** reduces back pressure on splanchnic organs ~ especially for esophageal varices
69
What is the most significant risk during a TIPS procedure?
Hemorrhage
70
What is the main complication in the pre-anhepatic phase?
Pulmonary aspiration of gastric contents
71
What is the primary complication during the anhepatic phase?
Profound reduction of CO
72
What is the primary complication during the Neohepatic phase?
Hyperkalemia
73
what is the most common indication for liver transplant?
Hep C baby
74
Can you put a TEE in a patient with esophageal varices?
Yes BUT no trans gastric views
75
When does the pre-anheptic stage begin and end?
Begins: surgical incision Ends: cross camping of portal vein, hepatic artery, and IVC
76
When does the anhepatic phase begin and end?
Begins: removal of native liver Ends: implantation of donor liver
77
When does the Neohepatic phase begin and end?
Begins: repercussion of donor liver Ends: biliary anastomosis
78
What are some anesthetic tips for the pre-anhepatic phase?
Goals: hemoglobin 7, platelets > 40,000, fibrinogen > 100 CVP low during case and increased to 10 prior to IVC clamp
79
What is the bicaval clamp?
Clamps are applied above and below liver during transplantation
80
What is the piggyback technique?
Partial obstruction of IVC flow
81
What is VVB?
Venovenous bypass ~ this is necessary if a patient does not tolerate piggyback technique
82
What should the warm ischemic time (donor liver is removed till donor liver is reperfused) not exceed?
30-60 mins
83
What happens following reperfusion?
Serum K will increase Restoration of blood flow washes out metabolic substances
84
What is the most important consideration during the Neohepatic phase?
Post-reperfusion syndrome
85
What is post-reperfusion syndrome?
It’s defined as hypotension > 30% below baseline for at least 1 minute during the first 5 mins of reperfusion of the donor liver Common: 10-60%
86
Which drugs relax the sphincter of Oddi?
Glucagon Glyco Atropine Narcan Nitroglycerin
87
Which sign is associated with cholecystitis?
Murphy’s sign! RUQ ~ Pain is worse on inspo

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