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Kidney + Liver + Endocrine > Liver > Flashcards

Liver Flashcards

(89 cards)

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1
Q

What is the function of Kupffer cells?

A

Removes bacteria before the blood drains into the vena cava

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2
Q

Where is bile produced?

A

Hepatocytes in the liver

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3
Q

What is the pathway of bile?

A

-Produced
-The canaliculi drains bile into the bile duct
-Bile ducts converge to make the common bile duct
-Cystic duct and the pancreatic duct join the common hepatic duct
-Sphincter of Oddi controls the flow of bile
-Contraction of the sphincter increases biliary pressure

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4
Q

How much CO and blood flow does the liver receive ?

A

30%
1500mL

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5
Q

Which two vessels supplies the liver?

A

Portal Ven

Hepatic artery

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6
Q

Breakdown of the two vessels that supplies the liver?

A

Portal Vein - 75% of Blood and 50% of O2

Hepatic artery - 25% of blood and 50% of O2

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7
Q

What determines portal blood flow?

A

Splanchnic circulation

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8
Q

What is the normal pressure of the portal vein? Sinusoids?

A

Portal 7-10

Sinusoids - 0

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9
Q

What is the diagnostic pressure for portal HTN of the portal vein? Sinusoids?

A

Portal >20

Sinusoids > 5

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10
Q

What is the hepatic arterial buffer response? What mediates this response? What blocks this?

A

If there is a reduction in portal vein flow, it is compensated by increased hepatic artery flow

Mediated through Adenosine

Blocked by severe liver disease

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11
Q

How does GA and neuraxial anesthesia affect hepatic blood flow?

A

Decreases it because of a decreased MAP

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12
Q

What coagulation factors are not produced by hepatocytes?

A

3 - Tissue factor
4- Calcium
vWF - (vasculature)

Still made in the liver but not hepatocytes

8 - antihemophilic factor (liver sinusoidal cells)

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13
Q

Which coagulation factors are dependent on vit K? Which anticoagulants are dependent on endothelial cells?

A

Factors - 2, 7, 9, 10

Anticoagulants - Protein C, Z, S

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14
Q

Which plasma proteins are produced by the liver?

A

Albumin - oncotic pressure and acts as a reservoir for acidic drugs

Alpha 1 - Reservoir for basic drugs

Pseudocholinesterase - metabolizes succ and ester locals

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15
Q

Gluconeogenesis, etc

A
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16
Q

What role does the liver play in amino acid deamination? What happens if they liver can’t?

A

Amino acid deamination allows the body to convert proteins to carbs and fats

this process creates large amount of ammonia. The liver converts ammonia to urea which the kidney eliminates

Failure to clear the ammonia leads to encephalopathy

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17
Q

Where does bili come from? How is it cleared?

A

Recycling of RBCs after 120 days

Eliminated through stool

Spleen
Bound to albumin
Conjugates with glucuronic acid to increase water solubility
Excreted into bile

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18
Q

What are the best tests of hepatic synthetic function? What is the best for acute injury?

A

PT - 12 to 14 seconds
Very sensitive because of short half life

Albumin - 4.0
Not sensitive because of long 21 day half life

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19
Q

Best tests for hepatocellular injury?

A

AST 10-40 units
ALT 10-50 units

Marked elevation of both suggests hepatitis

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20
Q

AST/ALT ratio greater than 2 suggests what?

A

Cirrhosis or alcoholic liver disease

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21
Q

3 tests for biliary duct obstruction? Most specific?

A

***5-Nucleotidase (0-11)

Y Glutamyl transpeptidase (0-30)

Alkaline phosphatase (45-115)

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22
Q

Liver photo

A
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23
Q

Which hepatitis has the highest incidence?

A

A - 50%
B - 35%
C- 15%
D - coinfection with B

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24
Q

How is each hepatitis transmitted?

A

A - oral fecal
B - IV or sex
C- IV
D- IV

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25
How is each hepatitis prevented?
A- pooled gamma globulin, Hep A vaccine B- Hep B immunoglobulin, Hep B vaccine C- Interferon + Ribavirin
26
How does Tylenol harm the liver? What is the treatment?
Tylenol creates a toxic metabolite called NAPQI but normally glutathione conjugates this Tylenol consumes all the glutathione which is required for phase 2 reactions Treatment is oral N-acetylcysteine within 8 hours of overdose
27
How do halogenated anesthetics harm the liver?
Des, Iso, Halothane are metabolized to inorganic fluoride ions and TFA Halothane is the worst SEVO does not make TFA
28
Most common causes of chronic hepatitis ?
1. Alcohol 2. Hep C
29
Can patients have surgery with hepatitis?
Acute hepatitis - NO Chronic - yes if stabilized
30
31
How can hepatic blood flow be maintained?
Use iso and avoid halothane Avoid PEEP Ensure normocapnia Liberal use of IV fluids Regional anesthesia as long as now coag issues
32
**Which drugs should be avoided with liver failure?
Tylenol Halothane Amiodarone Antibiotics: PCN, tetracycline, sulfas
33
How does alcohol affect MAC?
Chronic - increased Acute - decreased Alcohol potentiates GABA so an increased affect with benzos Alcohol inhibits NMDA
34
Early signs of alcohol withdrawal ? How soon?
6-8 hours after BAC returns to normal and peak at 24 hours Early - Tremors, hallucinations, nightmares
35
Late signs of alcohol withdrawal ? Treatment?
Increased SNS, N/V, agitation, confusion Treatments - beta blockers, alcohol, alpha 2 agonists
36
S/sx and treatment for delirium tremens?
S/sx - grand mal seizures, tachycardia, hypo/hypertension, combativeness Treatment - Diazepam or beta blockers
37
Why are alcoholics susceptible to Wernicke-Korsakoff syndrome?
They are deficient in B1 (thiamine) S/sx - loss of neurons in the cerebellum
38
Etiologies of cirrhosis photo
39
What is cirrhosis?
Healthy liver tissue is replaced with nodules and fibrotic tissue.
40
How does cirrhosis affect liver blood flow? Consequence?
Reduces blood flow and increases resistance - portal HTN Creates collateral vessels Drugs and toxins remain in the body longer
41
What is a MELD score?
Measures 3 factors Bili, INR, and creatinine Low risk < 10 Intermediate risk 10-15 High risk > 15
42
What is the child-pugh score?
Measures 5 factors Albumin, PT, bili, ascites, and encephalopathy Class A, 5-6 points = 10% risk of mortality Class B, 7-9 points = 30% risk Class C, 10-15 points = 80% Class C must be managed medically before surgery
43
How does cirrhosis affect SVR, BP, CO?
SVR and BP is decreased CO is increased
44
How does cirrhosis affect RAA\S?
Increased which leads to increased blood volume
45
How does cirrhosis affect peripheral blood flow?
Increased which leads to increased SvO2
46
How does cirrhosis affect response to vasopressors?
Decreased response
47
How does cirrhosis affect the heart?
Diastolic dysfunction
48
How does cirrhosis affect portal HTN? What does portal HTN lead to?
Creates portal HTN Increased to hepatic vascular resistance which increases back pressure to proximal organs Creates esophageal varices Splenomegaly which leads to thrombocytopenia
49
How does cirrhosis affect Ascites ?
Creates it Decreased oncotic pressure Decreased protein binding Increased Vd Hypotension
50
How does cirrhosis affect pulmonary?
Restrictive disease Respiratory alkalosis Hepatopulmonary syndrome Portopulmonary HTN
51
How does cirrhosis affect encephalopathy?
Decreased hepatic clearance which leads to increased ammonia which causes Cerebral edema and INCREASED ICP Reduce protein, give lactulose and abx
52
How does cirrhosis affect kidneys?
Hepatorenal syndrome - Decreased GFR which leads to kidney failure Renal hypoperfusion - Decreased GFR and Increased RAAS which leads to NA and H2o retention
53
What is a TIPS procedure? What is the biggest risk?
Bypasses hepatic circulation and shunts blood from the portal vein to the hepatic vein (outflow vessel) Reduces back pressure and reduces esophageal varices Bleeding is a high risk
54
Which hormone stimulates bile release?
Cholecystokinin (CCK) stimulates gallbladder contraction Released due to ingested food
55
Choley photo
56
What is cholecystitis? How is it treated?
Inflammation of the gallbladder Cholecystectomy
57
What is cholelithiasis? How is it treated?
Gallstones Cholecystectomy
58
What is choledocholithiasis? How is it treated?
Stones in the common bile duct ERCP
59
Who is at the highest risk for gallstones?
3 F's Fat Female 40
60
S/sx of gallstones?
Leukocytosis Fever RUQ pain - pain is worse during inspiration (Murphy's sign)
61
What is used to relax the sphincter of ODDI?
Glucagon*** - increased risk of PONV Also Naloxone Nitro Glyco Atropine
62
Which 3 organs does the celiac artery provide blood flow to?
Liver Spleen Stomach
63
Which 3 organs does the superior mesenteric artery provide blood flow to?
Pancreas Small intestine Colon
64
Which organ does the inferior mesenteric artery provide blood to?
Colon
65
Which 4 things increase splanchnic vascular resistance?
SNS stimulation Pain Hypoxia Propranolol
66
Hepatocytes produce?
Thrombopoietin Alpha-1 Factor 7
67
Which plasma proteins are synthesized in the liver?
all of them except immunoglobulins
68
What is Glycogenesis? Glycogenolysis? Gluconeogenesis?
Glycogenesis - Glucose is stored as glycogen Glycogenolysis- Glycogen is cleaved into glucose Gluconeogenesis- Glucose is created from non carbohydrate sources
69
Normal PT time? What does this measure?
12 - 14 seconds? Synthetic function
70
Normal Albumin? What does this measure?
3.5-5 g/dl Same as potassium Measures synthetic function
71
Normal AST and ALT? What do these measure?
AST- 10 - 40 ALT - 10- 50 Hepatocellular injury
72
Normal Bili? What does this measure?
0-11 Hepatic Clearance
73
Normal alkaline phosphatase? What does this measure?
45-115 units Biliary duct obstruction
74
Normal gamma glutamyl transpeptidase? What does this measure?
0-30 units Biliary duct obstruction
75
Normal 5 Nucleosidase? What does this measure?
0- 11 Biliary duct obstruction
76
Which hepatitis does not cause cirrhosis or cancer?
Hep A
77
Which three drugs are associated with drug induced hepatitis?
Halothane Tylenol Alcohol
78
What is the typical onset of delirium tremens after a patient stops drinking?
2-4 days
79
What are some changes seen in patients with cirrhosis of the liver?
- Right to left shunt -Respiratory alkalosis (breathing off acid) -Increased CO -Decreased GFR and SVR
80
What is the pre anhepatic phase?
Surgical incision to cross clamping Significant blood loss Risk for aspiration Will have hemodynamic instability Prevent hypothermia
81
What is the anhepatic phase?
Begins with removal of old liver and ends with implantation of new Patient will have no liver function New liver must be in within an hour *Lower K with hyperventilation, D50, insulin, bicarb, albuterol, CVVHD
82
What is the neohepatic phase?
Begins with reperfusion of new liver and ends with biliary anastomosis -**Highest risk for hyperkalemia -Avoid high CVP -Watch temp and electrolytes * Post reperfusion syndrome most important consideration. Hypotension more than 30% below baseline for 1 minute
83
What TEE views should be avoided with esophageal varices?
All transgastric
84
What special airway consideration for a liver transplant?
RSI for risk of aspiration
85
Which two ducts converge at the ampulla of Vater?
Pancreatic duct and the common bile duct
86
How does propranolol reduce hepatic blood flow?
Constricts the hepatic artery
87
Which zone of the liver is most prone to hypoxic injury?
Zone 3 - closest to central vein
88
Most significant risk factors for halothane hepatitis?
Female Fat Forty
89
Are collateral vessels formed in the inside or outside of the liver in cirrhosis?
Outside

Kidney + Liver + Endocrine (6 decks)

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