Module 9

Question 1

MODULE 9
Liver and GI and Anesthesia

KEY POINTS

1. The liver is the largest internal organ, accounting for 2% of the total body mass of adults. It receives _______(7) of the cardiac output via a dual afferent blood supply. The portal vein supplies _______(1) of the hepatic blood flow, whereas the hepatic artery supplies the remainder. Because of the higher oxygen content in the hepatic artery, each vessel provides roughly _______(2) of the hepatic oxygen supply.
2. The liver plays a pre-eminent role in the intermediary metabolism of nutrients (_______(3), _______(4), and _______(5)) and the detoxification of chemicals, including lipophilic medications. Liver dysfunction affects the metabolism of nutrients and xenobiotics, and negatively impacts nearly every other organ system.
3. Portal _______(6), the end result of hepatic injury and fibrotic changes, results in portosystemic shunts that bypass the liver’s metabolic and detoxification capabilities. When nitrogenous waste and other substances normally cleared by the liver enter the central circulation, hepatic encephalopathy ensues.

Answer 1

1. 75%
2. 50%
3. glucose
4. nitrogen
5. lipids
6. hypertension
7. 25%

Question 2

KEY POINTS

4. Additional complications of portal hypertension include variceal hemorrhage, ascites, and hepatorenal syndrome. Cardiac sequelae include hyperdynamic circulation due to _______(1) systemic vascular resistance, which results in an _______(2) in cardiac output.
5. Perioperative complications encountered by cirrhotic patients include liver failure, postoperative bleeding, infection, and renal failure. Patients with a model for end-stage liver disease (MELD) score of less than _______(3) have a low postoperative mortality and represent an acceptable surgical risk. End-stage liver disease patients with a risk of postoperative liver failure should have elective abdominal surgery at institutions with a liver transplant program. In patients with a MELD score of _______(4) or higher, the high mortality risk contraindicates elective procedures until after liver transplantation.
6. Medical management undertaken to optimize cirrhotic patients undergoing surgery should be directed toward treating active infection, minimizing vasoactive infusions, optimizing central blood volume and renal status, minimizing ascites, and improving encephalopathy and coagulopathy.
7. The perioperative risk of patients with end-stage liver disease depends more on the _______(5) and the degree of liver impairment than the anesthetic technique.

Answer 2

1. decreased
2. increase
3. 11
4. 20
5. operative site

Question 3

Dr. Lori Tolson
Case Scenario
A 66-year-old woman with a history of alcoholic cirrhosis and portal hypertension is admitted to the intensive care unit with altered mental status and low urine output. She has ascites and encephalopathy. Her kidney injury is acute with a creatinine clearance of 30 mL per minute. Her international normalized ratio (INR) is 3.0. Her hemoglobin level is 10.2 g per dL. She has a model for end-stage liver disease (MELD) score of 28 points. Her respiratory rate is 30 breaths per minute. She is scheduled for orthotopic liver transplantation.

Hepatic portal circulation. In this unusual circulatory route, a vein is located between two capillary beds. The hepatic portal vein collects blood from capillaries in visceral structures located in the abdomen and empties into the liver for distribution to the hepatic capillaries. Hepatic veins return blood to the _______(1), I; _______(2), L; _______(3), R; _______(4), S, superior.
From Patton KT. Anatomy & Physiology. 10th ed. St. Louis: Elsevier, 2019:685.

Liver Review
- Largest Internal Organ
- 2% of the total body mass of adults
- Receives 25% of cardiac output
- Oxygenated blood from the hepatic artery; nutrient-rich blood from portal vein
- Each vessel provides _______(5) of the hepatic oxygen supply

The liver is the largest internal organ accounting for 2% of the total body mass of adults. It receives 25% of the cardiac output. The liver receives blood from two sources - oxygenated blood from the hepatic artery and nutrient-rich blood from the portal vein. And each vessel provides roughly _______(6) of the hepatic oxygen supply. Sympathetic innervation from _______(7) to _______(8) controls resistance in the hepatic venules. Changes in compliance in the hepatic venous system contribute to the regulation of cardiac output and blood volume. In the presence of reduced portal venous flow, the hepatic _______(9) can increase flow by as much as 100% to maintain hepatic oxygen delivery. The reciprocal relationship between flow in the two afferent vessels is termed the “hepatic arterial buffer” response.

Answer 3

1. inferior vena cava
2. Inferior
3. Right
4. Superior
5. 50%
6. 50%
7. T3
8. T11
9. artery

Question 4

Sources of blood and oxygen supply to the liver.
The liver receives blood from two sources - oxygenated blood from the _______(1) and nutrient-rich blood from the _______(2). And each vessel provides roughly _______(3) of the hepatic oxygen supply.

Answer 4

1. hepatic artery
2. portal vein
3. 50%

Question 5

Anatomic and functional subdivisions of the liver. The _______(1) functional anatomic segments of the liver are demonstrated in this drawing. Each segment has its own _______(2) and _______(3).

Answer 5

1. eight
2. blood supply
3. biliary drainage

Question 6

Overall, the liver carries out essential metabolic, detoxifying, and regulatory functions to keep the body healthy. For a complete list of all the functions of the liver, please refer to Box 33.1 in Nagelhout. The liver metabolizes carbohydrates, proteins, fats, and vitamins and regulates energy balance. The liver plays a major role in the metabolism of nutrients such as glucose nitrogen and lipids and detoxifies chemicals, including lipophilic medications. Liver dysfunction affects the metabolism of nutrients and xenobiotics and negatively impacts nearly every other organ system. The liver is capable of _______(1) of amino acids, which is required for energy production or the conversion of amino acids to carbohydrates or fats. Deamination produces ammonia, which is toxic. Intestinal bacteria are an additional source of ammonia. The liver removes ammonia through the formation of _______(2).

Answer 6

1. deamination
2. urea

Question 7

Storage
The liver stores important nutrients like vitamin A, D, E, K, _______(1), iron, and minerals. It also stores glycogen which can be converted to glucose when the body needs energy. In patients with altered liver function, blood glucose concentration can rise several fold higher than the postprandial levels found in patients with normal hepatic function.
Regulation of Glucose levels must be a consideration in patients even if they aren’t Diabetic

Detoxification
The liver neutralizes chemicals and drugs in the blood and readies them for excretion.

Immune Function
The liver contains _______(2) cells which destroy bacteria and remove foreign particles from the blood. It produces immune factors and proteins that combat infections.

Filtration
The liver filters about _______(3) of blood per minute, removing toxins, waste products, bacteria, and old red blood cells.

Blood Clotting
The liver produces clotting factors and proteins that help the blood clot and prevent excessive bleeding.
All of the blood clotting factors, with the exception of factors _______(4) (tissue thromboplastin), _______(5) (calcium), and _______(6) (von Willebrand factor), are synthesized in the liver. Vitamin K is required for the synthesis of prothrombin (factor _______(7)) and factors _______(8), IX, and X.

Answer 7

1. B12
2. Kupffer
3. 1.4L
4. III
5. IV
6. VIII (We hate 3, 4, and 8)
7. II
8. VII (Think 1972)

Question 7

BOX 33.1 NAGELHOUT
Selected Essential Physiologic Functions of the Liver

• Carbohydrate metabolism
• Gluconeogenesis
• Glycogenolysis
• Glycogenesis
• Protein synthesis
• Albumin (maintenance of _______(1))
• Thrombopoietin (____(2) production)
• Amino acid synthesis
• Protein metabolism
• Bile production
• Lipid metabolism
• Lipogenesis
• Cholesterol synthesis
• Coagulation factor synthesis
• Production of factors ____(3)
• Insulin clearance
• Drug metabolism/transformation
• Bilirubin metabolism

Answer 7

1. osmolarity
2. Platelets
3. I, II, V, VII, IX, X, and XI

Question 7

Bile Production
- _______(7) cells produce bile, which is stored in the gallbladder.
- Bile contains bile salts and phospholipids that emulsify fats and aid in their digestion and absorption.
- Think of bile as an _______(1) detergent for fats.

Plasma Protein Production
- Albumin - _______(2) pressure, transport, antioxidant
- Albumin is the _______(3) abundant plasma protein made by the liver.
- It maintains oncotic pressure, transports lipids and hormones, and has antioxidant properties.
- Serum albumin levels reflect liver function and nutritional status.
- Coagulation factors - hemostasis, anticoagulation
- The liver makes most coagulation factors involved in the clotting cascade including prothrombin, fibrinogen, factors _______(4), and it also makes anticoagulant proteins _______(5) and _______(6).

Answer 7

1. alkalizing
2. oncotic
3. most
4. V, VII, IX, X
5. C
6. S
7. Liver

Question 7

Plasma Protein Production

Immunoglobulins - humoral immunity and defense
- The liver synthesizes immunoglobulins including IgG, IgA, _______(1).
- It does not produce _______(2) or _______(3).

C-reactive protein - inflammation modulation
- C-reactive protein - This acute phase reactant produced by the liver _______(4) during inflammation and infection.
- It activates complement and phagocytosis.

Ceruloplasmin - copper and iron homeostasis
- Ceruloplasmin - This _______(5)-binding glycoprotein made in the liver carries 90% of plasma copper and has _______(6) activity.

Lipoproteins - lipid transport and metabolism
- Lipoproteins - The liver produces _______(7) low-density and _______(8) lipoproteins which transport lipids through the circulation.

Protease inhibitors - tissue protection
- Protease inhibitors - _______(9) made by the liver protects tissues from proteases like elastase.
- Low levels increase risk of _______(10).

Cruising in my AMG

Answer 7

1. IgM
2. IgE
3. IgD
4. increases
5. copper
6. ferroxidase
7. very
8. high-density
9. Alpha-1 antitrypsin
10. emphysema

Question 7

Clinical Significance
- Levels indicate liver function and protein status
- Deficiencies cause edema, bleeding, lipid issues, infections
- The liver produces a wide range of vital plasma proteins involved in critical _______(1) processes.
- Dysfunction impairs _______(2), _______(3), _______(4).

Protein Metabolism

Plasma Protein Synthesis
- Albumin, clotting factors, complement, carriers like _______(5)
- Regulates blood _______(6) levels
- Acute phase proteins in _______(7)

Answer 7

1. physiological
2. transport
3. immunity
4. coagulation
5. transthyretin
6. amino acid
7. inflammation

Question 8

Protein Metabolism
- Here are some key points about the liver’s role in protein metabolism:
- Synthesis of plasma proteins - The liver synthesizes and secretes many essential plasma proteins like albumin, coagulation factors, complement proteins, carriers like _______(1), and lipoproteins.
- Amino acid metabolism - The liver metabolizes amino acids and converts excess amino acids to _______(9). It detoxifies ammonia by converting it to _______(2).
- Regulation of blood amino acid levels - The liver takes up amino acids from the blood and regulates systemic amino acid levels.
- Synthesis of acute phase proteins - In response to inflammation or injury, the liver increases production of certain plasma proteins called _______(3) proteins.
- Examples are _______(4) protein and serum _______(5).
- Gluconeogenesis - The liver can synthesize glucose from amino acids through gluconeogenesis. This helps maintain blood glucose when glucose supply is _______(6).
- Protein storage - The liver stores amino acids in the form of proteins like albumin and stores excess amino nitrogen from protein breakdown as _______(7).
- Transport proteins - The liver makes carrier proteins that transport various compounds like bilirubin, hormones, metals, drugs.
- Coagulation factors - The liver synthesizes most of the coagulation factors and fibrinolytic proteins involved in blood clotting and thrombus dissolution.
In summary, the liver plays a major role in plasma protein synthesis, amino acid metabolism, storage and transport, and glucose _______(8) related to proteins.

Answer 8

1. transthyretin
2. urea
3. acute phase
4. C-reactive
5. amyloid A
6. low
7. urea
8. homeostasis
9. glucose or ketone bodies

Question 9

Here is an improved 5-slide PowerPoint presentation on the liver’s vital role in protein metabolism:

• Slide 1 - Title:
  
  • The Liver: Central Role in _______(1)
• Slide 2 - Plasma Protein Synthesis
  
  • Albumin, clotting factors, complement, carriers like _______(2)
  • Regulates blood _______(3) levels
  • Acute phase proteins in _______(4)
• Slide 3 - Amino Acid Metabolism
  
  • Detoxifies ammonia by _______(5) synthesis
  • Converts excess amino acids to glucose or _______(6)
  • Gluconeogenesis from amino acids
• Slide 4 - Protein Storage & Transport
  
  • Stores amino acids and _______(7)
  • Transport proteins like bilirubin and _______(8) carriers
  • Coagulation factors for blood clotting
• Slide 5 - Conclusions
  
  • The liver synthesizes essential plasma proteins, metabolizes amino acids, converts amino acid nitrogen to urea, and regulates systemic amino acid and glucose levels through protein _______(9).

Answer 9

1. Protein Metabolism
2. transthyretin
3. amino acid
4. inflammation
5. urea
6. ketones
7. urea
8. hormone
9. metabolism

Question 10

Amino Acid Metabolism
- Detoxifies ammonia by _______(1) synthesis
- Converts excess amino acids to glucose or _______(2)
- Gluconeogenesis from amino acids

Protein Storage & Transport
- Stores amino acids and _______(3)
- Transport proteins like bilirubin and _______(4) carriers
- Coagulation factors for blood clotting
- Protein storage - The liver stores amino acids in the form of proteins like _______(5) and stores excess amino nitrogen from protein breakdown as _______(6).
- Transport proteins - The liver makes carrier proteins that transport various compounds like bilirubin, hormones, _______(7), drugs.
- Coagulation factors - The liver synthesizes most of the coagulation factors and _______(8) proteins involved in blood clotting and thrombus dissolution.

In summary, the liver plays a major role in plasma protein synthesis, amino acid metabolism, storage and transport, and glucose _______(9) related to proteins.

Answer 10

1. urea
2. ketones
3. urea
4. hormone
5. albumin
6. urea
7. metals
8. fibrinolytic
9. homeostasis

Question 11

Fibrinogen
- Soluble plasma glycoprotein synthesized by the _______(1) and _______(2) (bone marrow cells)
- During coagulation, thrombin converts fibrinogen into fibrin forming the fibrin meshwork of a blood clot
- ~_______(3) is produced by megakaryocytes which helps maintain adequate fibrinogen level even in severe liver disease

Fibrinogen is a soluble plasma glycoprotein that is synthesized by the liver and megakaryocytes (bone marrow cells). During coagulation, thrombin converts fibrinogen into _______(4) which forms the fibrin meshwork of a blood clot.

• While the liver synthesizes the majority of fibrinogen, approximately _______(5) is produced by megakaryocytes in the bone marrow. The contribution from megakaryocytes helps maintain adequate fibrinogen levels even in severe liver disease.
• So in summary, fibrinogen stands out as the main plasma protein not solely produced by hepatocytes in the liver. While the liver makes most _______(6), megakaryocytes provide the remainder.

Answer 11

1. liver
2. megakaryocytes
3. 10-15%
4. fibrin
5. 10-15%
6. fibrinogen

Question 12

Medication Metabolism
- Cytochrome P450 enzymes metabolize drugs through chemical reactions like oxidation, reduction, hydrolysis, etc.
- P450 system metabolizes ~_______(1) of all medications
- Phase I modifies drug with functionalization actions resulting in loss of pharmacologic activity
- Phase II conjugates the metabolite with a second molecule (glucuronic acid, sulfate, glutathione, amino acid, or acetate) forming a _______(2) link
- Leads to deactivation and transformation of substances into benign byproducts
- Medication Metabolism: The liver plays a major role in metabolizing medications and drugs that enter the body. Here are some key points about the liver and drug metabolism:
- Enzymes in liver cells called cytochrome P450 enzymes metabolize drugs through chemical reactions like oxidation, reduction, _______(3), etc. This makes drugs more water-soluble for easier excretion into the bile or urine.
- The cytochrome P450 system accounts for metabolizing about _______(4) of all medications. The enzymes transform drugs into metabolites that are more _______(5) and can be excreted more readily.
- Drug metabolism in the liver occurs in two phases - phase I modifies the drug by introducing or unmasking a functional group, phase II conjugates the drug or metabolite with compounds like _______(6) to increase water solubility.
- The liver can activate a prodrug into its active form through metabolism. It can also convert an active drug into an _______(7) metabolite, reducing its pharmacological effects.
- Liver impairment or disease like cirrhosis can significantly impact the metabolism and clearance of many drugs. Doses may need adjustment in such patients to avoid toxicity.
- Factors like age, genetics, drug interactions, and comorbidities affect hepatic metabolizing enzymes, altering the efficacy and side effects of medications.
- The liver helps detoxify and excrete drugs, but drug metabolites may also be more _______(8) than the parent drug in some cases.
In summary, the liver’s role in drug metabolism through specialized enzymes has a major influence on the pharmacological actions and side effects of medications.

Answer 12

1. 75%
2. covalent
3. hydrolysis
4. 75%
5. polar
6. glutathione
7. inactive
8. toxic

Question 13

Medication Metabolism
- _______(1)% of currently manufactured drugs are metabolized by a single CYP
- Rate of metabolism can be increased or decreased with coadministration of 2 drugs metabolized by the same enzyme system
- Enzyme induction hastens metabolism and promotes tolerance

Liver Function Tests
- Measure levels of enzymes, proteins, and bilirubin to assess liver function and identify liver injury
- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
- ALP, 5’-NT, GGT
- Bilirubin: conjugated vs unconjugated
- Measure levels of _______(2), _______(3), and bilirubin to assess liver function and identify liver injury.

Answer 13

1. 50%
2. enzymes
3. proteins

Question 14

Liver Function Tests

1) Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) - elevations indicate liver cell damage.
- Because A_______(5)T is also found in nonhepatic tissues (including the heart, skeletal muscle, kidney, and brain), elevations are not specific for hepatic disease.
- A_______(6)T is primarily localized to the liver. Fatty liver and chronic infections are associated with mild (several fold) elevations of AST and ALT.
- Acute hepatitis produces larger increases, but the highest concentrations, which can exceed 50 times normal, are seen with acute hepatic necrosis.
- The AST/ALT ratio may be helpful in differentiating alcoholic liver disease, in which the ratio is typically greater than _______(1),
- from viral hepatitis, which is associated with a ratio lower than _______(3).

2) Indices of bile flow obstruction include serum levels of alkaline phosphatase (ALP), 5’-nucleotidase (5’-NT), γ-glutamyl transferase (GGT). Alkaline phosphatase (ALP) - increases with bile duct obstruction.

3) Bilirubin - Elevated levels of unconjugated bilirubin indicate an excess production of bilirubin (hemolysis) or a decrease in the uptake and conjugation of bilirubin by hepatocytes.
- Conjugated bilirubin is _______(2) by impaired intrahepatic excretion or extrahepatic obstruction.
- Even with complete biliary tract obstruction, the bilirubin rarely exceeds _______(4) because of renal excretion of conjugated bilirubin.

normal ranges for common liver function tests:

1. Alanine transaminase (ALT): 7-56 units per liter (U/L)
2. Aspartate transaminase (AST): 10-40 U/L
3. Alkaline phosphatase (ALP): 40-129 U/L
4. Albumin: 3.5-5.0 grams per deciliter (g/dL)
5. Total protein: 6.3-7.9 g/dL
6. Bilirubin: 0.1-1.2 milligrams per deciliter (mg/dL)
7. Gamma-glutamyltransferase (GGT): 9-48 U/L
8. Lactate dehydrogenase (LD): 122-222 U/L
9. Prothrombin time (PT): 9.4-12.5 seconds

Answer 14

1. 2
2. elevated
3. 1
4. 35 mg/dL
5. S
6. L

Question 15

• Albumin
• PT/INR
• ALT more specific for liver injury than A________(1)T. ________(2) and ________(3)indicate cholestatic liver disease
  
  • Table 33.2 (broken down by AK from Nagelhout)
    
    • Aminotransferases:
      
      • ALT (___(4) units/L)
        
        • Abnormality: Leakage from damaged tissue.
        • Liver Diseases: Mild-moderate liver disease, Hepatitis.
        • Extrahepatic: More specific than AST for hepatic injury, organs: muscle, brain, kidney.
      • AST (___(5) units/L)
        
        • Abnormality: Leakage from damaged tissue.
        • Liver Diseases: Many liver diseases, Hepatitis, cirrhosis.
        • Extrahepatic: Non-specific, organs: heart, kidney, brain, pancreas, muscle.
    • AP ( ___(6) units/L)
      
      • Abnormality: Overproduction & leakage.
      • Liver Diseases: Many liver types, e.g. tumor, cholestasis.
      • Extrahepatic: Bones, tumors.
    • GGTP (___(7) units/L)
      
      • Abnormality: Overproduction & leakage.
      • Liver Diseases: Hepatitis, alcoholism.
      • Extrahepatic: Kidney, spleen, pancreas, heart, lungs, brain.
    • 5’ nucleotidase (____(8) units/L)
      
      • Abnormality: Overproduction & leakage.
      • Liver Diseases: Similar to AP.
      • Extrahepatic: Many tissues, but specific for liver.
    • Bilirubin (____(9) mg/dL)
      
      • Abnormality: Decreased hepatic clearance.

Answer 15

1. S
2. ALP
3. GGT
4. 0–55
5. 0–55
6. 45–115
7. 0–30
8. 0–11
9. 0–1

Question 16

• Liver Diseases: Many types, including drug-induced.
  
  • Extrahepatic: Increased breakdown, injury from hemolysis or muscle.
• Prothrombin time (PT) (_______(1)) seconds)
  
  • Abnormality: Decreased synthesis.
  • Liver Diseases: Liver failure, biliary obstruction.
  • Extrahepatic: Vitamin K deficiency, malnutrition, anticoagulants.
• Albumin (_______(2))
  
  • Abnormality: Synthesis decrease; increased catabolism.
  • Liver Diseases: Chronic liver failure.
  • Extrahepatic: Nephrotic syndrome, malnutrition, inflammation.

Answer 16

1. 10.9–12.5
2. 3.5–5g/dL

Question 17

4) Albumin - _______(1) in liver dysfunction.
- Prothrombin time (PT) - _______(2) in liver dysfunction.
- Tests of hepatic synthetic function focus on the measurement of serum albumin and coagulation testing.
- Although the liver is the primary site of albumin synthesis, excessive protein losses (enteropathy, burns, nephrotic syndrome) can also result in low albumin levels.
- Because of its 3-week half-life, serum albumin is not a reliable indicator of acute liver disease.

In contrast, the _______(4) and _______(5) are sensitive indicators of hepatic disease because of the short half-life of factor VII.
- The PT depends upon sufficient intake of vitamin K, which in turn depends upon adequate biliary secretion of bile salts. In patients with biliary obstruction, the PT can be prolonged despite preserved hepatic function.
- Other conditions that can affect the PT in the absence of liver disease include congenital coagulation factor deficiencies, consumptive coagulopathies such as disseminated intravascular coagulation (DIC), and warfarin therapy.
- ALT is more specific for liver injury than AST. _______(3) and GGT indicate cholestatic liver disease.
- Other specific tests check for liver diseases like iron overload, autoimmune hepatitis, metabolic disorders.
- In summary, _______(6) provide clinical chemistry evidence of liver injury and impaired function, but may not pinpoint exact etiology without biopsy. Still very useful for screening and monitoring.

Answer 17

1. decreased
2. prolonged
3. ALP
4. prothrombin time (PT)
5. international normalized ratio (INR)
6. LFTs

Question 18

QUIZ QUESTIONS:
1) Recall that the liver is divided into three separate zones. Which zone is affected most by hypoxia and reactive intermediates from biotransformation?
- _______(1) and reactive metabolic intermediates from biotransformation affect zone _______(2) more prominently than other zones.

2) Which liver cells have the greatest quantity of cytochrome P450 enzymes and are the site of anaerobic metabolism?
- _______(3) hepatocytes have a greater quantity of cytochrome P450 enzymes and are the site of _______(4) metabolism.

The liver is anatomically divided into three zones, each with distinct physiological and pathological roles: Chat GPT

1. Zone 1 (Periportal Zone):
   
   • Located around the portal triads, which contain the portal vein, hepatic artery, and bile duct.
   • Receives the most oxygenated blood, making it the first zone exposed to nutrients, toxins, and drugs from the portal circulation.
   • Most resistant to ischemia, but susceptible to toxic injury.
   • Predominantly involved in oxidative energy metabolism, gluconeogenesis, urea synthesis, and cholesterol synthesis.
2. Zone 2 (Midzonal Zone):
   
   • Positioned between zones 1 and 3, it represents an intermediate zone with intermediate blood flow and oxygen levels.
   • Less active metabolically compared to zone 1 but more so than zone 3.
   • It serves as a buffer zone and can be affected in extreme cases of either zone 1 or zone 3 injuries.
3. Zone 3 (Centrilobular Zone):
   
   • Surrounds the central veins, which drain blood out of the liver into the systemic circulation.
   • Receives the least oxygenated blood, making it the most susceptible to ischemia.
   • Contains a high concentration of cytochrome P450 enzymes, making it the primary site for drug and alcohol metabolism.
   • Zone 3 hepatocytes are most affected in conditions like alcoholic liver disease and are the first to show fatty change and necrosis in various liver diseases.

Answer 18

1. Hypoxia
2. 3
3. Pericentral
4. anaerobic

Question 19

Effects of Anesthesia on Liver Function

• General and Regional Anesthesia Impact:
  
  • Reduces hepatic blood flow in a _______(1)-dependent manner.
  • Reduction in mean arterial pressure and cardiac output impacts hepatic blood flow _______(2).
• Vasoconstriction in Splanchnic Circulation:
  
  • Triggered as a sympathetic reflex due to decreased mean arterial pressure.
  • Impairs hepatic blood flow.
• Effects of Volatile Anesthetics:
  
  • Isoflurane:
    
    • Increases hepatic blood flow through _______(3).
    • However, portal blood flow is likely _______(4).
• Regional Anesthetic–Induced Sympathectomy:
  
  • Examples: Epidural, subarachnoid blockade.
  • Main effect: Causes hypotension.
  • Result: Decreased splanchnic blood flow.

Answer 19

. dose
2. proportionally
3. vasodilation
4. reduced

Question 20

• Positive pressure ventilation - Mechanical ventilation with positive pressure can impair venous return and cardiac output, reducing perfusion.
  
  • Know the effects of hyper- and hypocapnia on blood flow.
• Vasodilation - Drugs used during anesthesia like inhaled anesthetics, propofol, opioids can cause systemic vasodilation —→ _______(1) hepatic vascular resistance and blood flow.
• Hypotension - Low blood pressure _______(2) perfusion pressure to the liver.
  
  • Causes include hypovolemia, blood loss, effects of anesthetic drugs.
• Increase in central venous pressure - Factors like mechanical ventilation, fluid overload, heart failure can increase CVP, ____a. hepatic blood flow.
• Hepatic vascular occlusion - Surgical manipulation during procedures like liver resection or transplant can directly occlude inflow or outflow vessels.
• Low cardiac output - Myocardial depression, dysrhythmias, decreased intravascular volume can reduce cardiac output and hepatic perfusion.
• Endothelial dysfunction - Coexisting conditions like sepsis, ischemia-reperfusion injury can impair vasodilation needed for blood flow.
• Compression of IVC - Improper positioning or abdominal packing in surgery that interfere vena cava can obstruct hepatic venous return.
• Careful titration of anesthesia, intraoperative monitoring, and avoiding factors that reduce perfusion pressure or cardiac output are key to maintain adequate hepatic circulation.

Answer 20

1. decreasing
2. reduces
   a. hindering

Question 21

Spinal Anesthesia
- Spinal anesthesia induces sympathetic blockade and vasodilation
- Redistributes blood flow to splanchnic vascular bed
- Vascular resistance reduced in hepatic arterial and portal circulation
- Vasodilation mediated by decreased vasoconstrictor hormones
- Spinal anesthesia produces sympathetic blockade and vasodilation peripherally, which helps _______(5) or even _______(1) hepatic perfusion compared to general anesthesia.

• However, _______(6) spinal levels (_______(2) and above) can impair cardiac output which may reduce hepatic blood flow.
• The reduction in systemic vascular resistance from spinal anesthesia causes blood to preferentially distribute to the _______(3) vasculature.
• Spinal anesthesia _______(4) release of hepatic vasoconstrictive hormones like angiotensin, vasopressin, and catecholamines, promoting hepatic vasodilation.

Answer 21

1. increase
2. T5-T6
3. splanchnic
4. decreases
5. maintain
6. high

Question 22

Spinal Anesthesia Liver

• Hypotension common side effect requiring prompt treatment
• _______(4) block can impair cardiac output and hepatic perfusion
• May better preserve hepatic blood flow compared to general anesthesia
• Use caution with epinephrine in spinal injectate
• Hypotension is common with spinal anesthesia and must be promptly treated with fluids or _______(1) to prevent hypoperfusion.
• Spinal anesthesia may be preferred over general anesthesia in some liver surgeries since it better preserves hepatic blood flow.
• Use of epinephrine in local anesthetic solutions can transiently reduce hepatic perfusion due to _______(2)-receptor mediated vasoconstriction.
• So in summary, spinal anesthesia alone does not typically impair hepatic circulation, but measures should be taken to prevent high block and treat any resulting hypotension. The sympathetic blockade helps redirect blood to the _______(3) vessels.

Answer 22

Answers:
1. vasopressors
2. alpha
3. splanchnic
4. High

Question 23

Volatile Anesthetic Selection for Liver Procedures

• Reduction in Hepatic Blood Flow
• Halothane> Desflurane>Sevoflurane>Isolfurane
• Anesthetic agents reduce hepatic blood flow by _______(4) after induction
• _______(5) increases hepatic blood flow via direct vasodilation properties
• _______(1) causes the greatest reduction in hepatic blood flow and _______(2) has slightly greater hepatic effects than sevoflurane and isoflurane.
• Isoflurane and sevoflurane cause less disturbance in hepatic arterial blood flow than other inhaled anesthetic agents and are therefore preferred for patients with liver disease.
• The risk of hepatic injury is seen in the use of halothane where minor injury can occur in _______(6) of patients and a major injury can lead to hepatotoxicity which is a severe hepatic reaction with elements of autoimmune allergy.
• Review the clinical features of halothane hepatitis listed in box 33.3

Answer 23

Answers:
1. Halothane
2. desflurane

4. 30-50%
5. Isoflurane
6. 10-30%

Question 24

BOX 33.3 Clinicopathologic Features of Halothane Hepatitis

• Estimated incidence
  
  • After first exposure: _______(1)
  • After multiple exposures: _______(2)
• Female-to-male ratio: 2:1
• Latent period to first symptom
  
  • After first exposure: _______(3) days (11 days to jaundice)
  • After multiple exposures: _______(4) days (6 days to jaundice)
• Risk factors
  
  • Older age
  • Female gender
  • Two or more exposures documented in 60%–90% of cases
  • Obesity
  • Familial predisposition
  • Induction of CYP1 by phenobarbital, alcohol, or isoniazid
• Clinical features
  
  • Jaundice as presenting symptom in 25% (serum bilirubin: 3–50 mg/L)
  • Fever in 75% (precedes jaundice in 75%; chills in 30%)
  • Rash in 10%
  • Myalgia in 20%
  • Ascites, renal failure, and/or gastrointestinal hemorrhage in 20%–30%

Eosinophilia in 20%–60%
Serum ALT and AST levels: 25–250 x ULN
Serum alkaline phosphatase level: 1–3 x ULN
Histopathologic features
Zone 3 massive hepatic necrosis in 30%; submassive necrosis in 70% (autopsy series)
Inflammation usually less marked than in viral hepatitis
Eosinophilic infiltrate in 20%
Granulomatous hepatitis occasionally
Course and outcome
Mortality rate (pretransplantation era): 10%–80%
Symptoms can resolve within 5–14 days
Full recovery can take 12 wk or longer
Chronic hepatitis not well documented
Adverse prognostic findings
Age >40 yr
Obesity
Short duration to the onset of jaundice
Serum bilirubin level >20 mg/dL
Coagulopathy

Answer 24

Answers:
1. 0.3–1.5/10,000
2. 10–15/10,000
3. 6 days
4. 3 days

Question 25

Halothane Hepatitis

Apex
- Metabolism: _______(1) halothane, _______(2) iso, _______(3) des
- Immune mediated reaction
- Risk factors:
- CYP2E1 induction
- > 40 yo
- Female
- Obesity
- Greater than 2 exposures

OpioidsSS
- All opioids have been implicated in causing a spasm of the _______(4).
- Lower incidence with Fentanyl
- Treatment includes _______(5) or _______(6)
- Atropine, glyco, glucagon and nitro may also be effective

Answer 25

Answers:
1. 20%
2. 0.2%
3. 0.02%
4. Oddi sphincter
5. nalbuphine
6. naloxone

Question 26

Diseases of the Liver (Mikie Start)

• Hepatitis
  
  • Acute
  • Viral
  • Chronic
  • _______(1) Induced
• Cirrhosis
  
  • Histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury
• Portal Hypertension
  
  • Portal hypertension is abnormally high blood pressure in the portal vein system, which carries blood from the intestines, spleen, pancreas and _______(2) to the liver.
• Acute hepatitis presents with variable clinical manifestations.
  
  • They can include mild inflammatory increases in serum transaminase levels to fulminant hepatic failure.
  • The cause of this syndrome is usually exposure to an infectious virus, hepatotoxic substances and adverse drug reactions.
  • Review box 33.4 for our management of patients with acute hepatitis. Note that because of reduced pseudocholinesterase activity, neuromuscular blocking agents may be _______(4).

Answer 26

Answers:
1. Drug
2. gallbladder

4. prolonged

Question 27

• _______(8) hepatitis is the most leading cause of liver cancer and the most common reason for transplantation. There are many types of viral hepatitis but typically A, B and C occur most often in the US.
  
  • Hepatitis _______(1) and _______(2) are transmitted by the oral-fecal route
  • Hepatitis _______(3), _______(4), and _______(5) are transmitted by contact with body fluids and physical contact with disrupted cutaneous barriers.
• Chronic hepatitis
  
  • occurs in one to 10% of acute hepatitis B infections and in 10 to 40% of hepatitis C infections but does not occur in hepatitis A infections.
  • Hepatic failure and fatal chronic hepatitis are marked by clinical manifestations such as _______(6) from esophageal varices.
  • Plasma albumin levels are usually _______(7) as a result of synthetic dysfunction and the PT is prolonged.

Answer 27

Answers:
1. A
2. E
3. B
4. C
5. D
6. multi organ system failure encephalopathy and hemorrhage
7. low
8. Viral

Question 28

_______(1) hepatitis is probably the most common form of drug induced hepatitis.
- Apex: 2nd most common hep C
- These patients are likely to have an increase in perioperative complications and an increase in mortality rate when in alcohol withdrawal.
- Apex:
- Inc. PT
- Dec. Albumin
- Acute - non emergent surgery should be postponed
- Iso or sevo (maintains liver blood flow)
- Avoid peep
- Avoid hepatotoxic drugs/ inhibit hepatic enzymes
- Reduced mac
- Chronic - may proceed with surgery as long stable
- Alcohol impairs pharyngeal reflexes → full stomach
- Withdrawal
- s/s starts 6-8hrs
- Peaks at 24-36 hrs
Encounters with acutely intoxicated patients may rarely occur in the perioperative setting, but for those of us working in trauma centers, we may see these kinds of patients more often.
- Note that alcohol inhibits NMDA receptors but increases GABA receptor activity.
- Causes impairment of hepatic oxidation of fatty acids, lipoprotein synthesis and secretion, and fatty acid esterification.
- There are enhanced effects of benzodiazepines barbiturates propofol and other CNS depressants.
- Overall, acute intoxication reduces MAC.

Answer 28

1. Alcoholic

Question 29

Diseases of the Liver cont.

• Viral hepatitis can be caused by hepatitis A (HAV), B (HBV), C (HCV), D (HDV), and E (HEV) viruses
• Any of these variations can lead to serious illness and death
• HAV has acute symptomology
• HBV and HCV are associated with significant chronic sequelae
• _______(4) rarely affect the liver chronically
• The most common reason for liver transplantation in developing countries is both _______(1) and _______(2)
• Nonalcoholic steatohepatitis (NASH)
  
  • involves inflammation with hepatocyte injury and may progress to cirrhosis and hepatocellular carcinoma.
  • NASH has become the most common chronic liver disease worldwide and the _______(3) indication for liver transplantation in the United States.

Answer 29

Answers:
1. HBV
2. HCV
3. fastest growing
4. HAV and HEV

Question 30

SO VEry HElpful against Hepatitis

Current treatment regimens

• Patients receive 2 direct acting antiviral drugs that target specific steps within the HCV replication cycle with or without interferon for a duration of 8 to 12 weeks
• Antiviral drug choice and treatment duration are based on
  
  • The genotype of HCV
  • Stage of liver disease
  • Presence of cirrhosis
  • Previous response to interferon
• Genotype 1A is the most common form in the US (70%) and is treated with _______(1)/_______(2) drug combination
• These drugs provide a rate of infection clearance of 98% in genotype 1A and 99% in genotype 1B

Answer 30

Answers:
1. sofosbuvir
2. velpatasvir

Question 31

BOX 33.4 Anesthetic Management of the Patient With Acute Hepatitis

Preserve hepatic blood flow:
- Use isoflurane or desflurane and avoid _______(1)
- Maintain normocapnia
- Avoid _______(2) if possible
- Provide adequate/liberal intravenous hydration
- Consider regional anesthesia if coagulation is acceptable and the procedure allows

Avoid medications with potential for hepatotoxicity or inhibition of CYP450:
- Halothane
- Acetaminophen
- Sulfonamides
- Tetracycline
- Penicillin
- Amiodarone

Thoughtful titration of neuromuscular blocking agents may be prolonged in patients with liver disease because of:
- Reduced pseudocholinesterase activity
- Decreased biliary excretion
- Larger volume of distribution

CYP450, Cytochrome P450; PEEP, positive end-expiratory pressure.

Answer 31

Answers:
1. halothane
2. PEEP

Question 32

Pregnancy-related Liver Diseases
- 3-5% of pregnancies
- Common causes: hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy (AFLP)
- Hyperemesis gravidarum: _________(1) trimester, risk factors: hyperthyroidism, molar pregnancy, multiple pregnancies; up to 20-fold elevation of liver enzymes, but not bilirubin
- HELLP: most common of later pregnancy liver diseases; microangiopathic hemolytic anemia (MAHA), elevated liver enzymes, and low platelet count in the preeclamptic patient comprises the HELLP syndrome and occurs in 20% of severely preeclamptic patients; up to —(2) maternal mortality

Answer 32

1. 1st
2. 25%

Question 33

Cirrhosis and Portal Hypertension

• Hepatocyte necrosis leading to deterioration in liver function →
• Liver parenchyma is replaced by fibrous and nodular tissue →
• Distorts, compresses, and obstructs normal portal venous blood flow →
• Portal hypertension develops
• Cirrhosis is defined as a histological development of regenerative nodules surrounded by fibrous brands in response to chronic liver injury which leads to _______(1) and _______(2).
• Cirrhosis may be caused by a variety of diseases, but the resultant anatomic alterations secondary to hepatocyte necrosis are the primary cause of the deterioration in liver function.
• Overtime, the liver parenchyma is replaced by _______(3), which distorts, compresses, and obstructs normal portal venous blood flow. Portal hypertension develops and impairs the ability of the liver to perform various metabolic and synthetic processes.
  
  • Refer to Nagelhout box 33.6 on page 716 for various causes of cirrhosis.

Answer 33

Answers:
1. portal hypertension
2. end stage liver disease
3. portal hypertension and end stage liver disease.

Question 34

Apex Cirrhosis
- Cell death → fibrotic hepatic tissue
- As blood vessels reduce → portal hypertension
- Unable to clear vasodilating substances
- Hyperdynamic circulation (High CO + low SVR)
- Needs just the TIPS! Procedure
- Sig rx is _______(1)

Answer 34

Answers:
1. hemorrhage

Question 35

What defines portal hypertension? Here is a brief overview of portal hypertension:
- Portal hypertension is abnormally high blood pressure in the portal vein system, which carries blood from the intestines, spleen, pancreas and gallbladder to the liver.
- It is defined as a hepatic venous pressure gradient exceeding _______(1), becoming clinically significant when it is >_______(2) mm Hg, at which point varices start to develop.
- Beyond a gradient of 12, very seal bleeding and ascites develop.
- The average portal vein pressure is _______(3) to _______(4) mmHg, which exceeds hepatic venous pressure by _______(5) mmHg.
- This increased pressure develops when there is resistance to blood flow through the portal circulation.
- This resistance most often arises from cirrhosis, which causes scarring and damage to the liver tissue.
- Other less common causes of portal hypertension include clotting disorders and blockages from liver inflammation or cancer.
- As a result of the high pressure, blood gets backed up and often gets diverted through collateral vessels that bypass the liver.
- This can lead to enlargement of veins (varices) in the esophagus, stomach, intestines, and rectum.

Answer 35

Answers:
1. 6 mmHg
2. 10
3. 8
4. 10
5. 4 to 5

Question 36

Portal Hypertension

• Portal _______(7), the end result of hepatic injury and fibrotic changes, results in Porto systemic shunts that bypass the liver’s metabolic and detoxification capabilities.
  
  • When nitrogenous waste and other substances normally cleared by the liver enter the central circulation, hepatic and _______(1) ensues.
• Key complications of portal hypertension include:
  
  • 1) _______(2) - ruptured varices are a leading cause of death
  • 2) _______(3) - fluid accumulation in the abdominal cavity
  • 3) Hepatic _______(4) - confusion and altered mental state
• Cardiac sequelae include hyperdynamic circulation due to _______(5) systemic vascular resistance, which results in an increase in cardiac output.
• Diagnosis is through measuring the pressure gradient between the _______(8) vein and _______(6) cava
  
  • typically via splenic or hepatic vein catheterization.

Answer 36

Answers:
1. encephalopathy
2. Variceal bleeding
3. Ascites
4. encephalopathy
5. decreased
6. inferior vena
7. hypertension
8. portal

Question 37

Cirrhosis and Portal Hypertension

• Definition
  
  • Abnormally high pressure in the portal vein system
  • Hepatic pressure gradient >_______(1)mmHg, clinically significant >_______(2)mmHg
  • Average portal vein pressure is _______(3)-_______(4)mmHg
• Causes
  
  • Cirrhosis
  • Clotting disorders
  • Blockages from liver inflammation or cancer
• End Result
  
  • Blood is backed up
  • Diversion through collateral vessels bypassing liver
  • Enlargement of veins in the esophagus, stomach, intestines, and rectum

Key complications of portal hypertension include:
1. _______(5) bleeding - ruptured varices are a leading cause of death
2. _______(6) - fluid accumulation in the abdominal cavity
3. Hepatic _______(7) - confusion and altered mental state
- Cardiac sequelae include hyperdynamic circulation due to _______(8) systemic vascular resistance, which results in an _______(9) in cardiac output.
- Diagnosis is through measuring the pressure gradient between the portal vein and inferior vena cava, typically via _______(10) or hepatic vein catheterization.

Answer 37

Answers:
1. 6
2. 10
3. 8
4. 10
5. Variceal
6. Ascites
7. encephalopathy
8. decreased
9. increase
10. splenic

Question 38

Cirrhosis and Hemostasis

• Cirrhotic patients are considered to have a bleeding diathesis vs DIC which is a thrombotic diathesis.
• Cirrhosis leads to _______(1) (up to 90% of platelets may be in the spleen) and clotting factor deficiencies
• Decrease in levels of protein _______(2) and _______(3) balance the decreased levels of procoagulants
• Thus they are at risk for both bleeding as well as thrombosis (due to relatively elevated levels of factors _______(4) and _______(9)
• _______(5) is a well-known feature of cirrhosis.
  
  • Estimates of incidence range from _______(6) to 64% of chronic cirrhotics, but platelet counts below 30,000/mm^3 are rare.
  • Because the liver is the primary site of thrombopoietin production, decreased levels of thrombopoietin contribute.
  • Other factors include immunologic mechanisms, direct bone-marrow suppression, and consumptive processes such as DIC.
  • However, the primary cause is _______(7) sequestration in the setting of portal hypertension.
  • Up to 90% of the platelet population may be sequestered in the _______(8).
  • Elevated levels of von Willebrand factor are felt to compensate for decreased platelet counts, augmenting the platelet–endothelial cell interaction on vessel walls.

Answer 38

Answers:
1. thrombocytopenia
2. C
3. S
4. VIII
5. Thrombocytopenia
6. 30%
7. splenic
8. spleen
9. von Willebrand factor

Question 39

Hepatopulmonary Syndrome

• _______(6) hypoxemia caused by intrapulmonary vascular dilatations
• Triad of portal
  
  • _______(7)
  • _______(1)
  • _______(8)
• A:a gradient >_______(2)
• Poor tolerance of gravitational effects on pulmonary blood flow leading to platypnea-orthodeoxia:
  
  • _______(9) worsens hypoxemia, _______(10) improves oxygenation
• HPS is characterized by arterial hypoxemia caused by intrapulmonary vascular dilatations.
  
  • The classical triad of portal hypertension, hypoxemia, and pulmonary vascular dilatations characterizes HPS.
• An alveolar to arterial oxygen gradient of greater than _______(3) mm Hg and pulmonary vascular dilatation documented by delayed, contrast-enhanced echo with _______(11) heart detection of microbubbles greater than _______(12) cardiac cycles is considered diagnostic of HPS.
• The classic hypoxic pulmonary vasoconstriction response to hypoxemia is impaired and leads to poor tolerance of gravitational effects on pulmonary blood flow leading to _______(4).
• This is a paradoxical increase in breathlessness and decrease in arterial partial pressure of oxygen; it occurs when a patient moves from supine to upright because of abnormal pulmonary vessel size.
• There is no known pharmacologic therapy to treat HPS.
  
  • The outcome of patients with the syndrome who do not receive a transplant is poor.
• In platypnea-orthodeoxia, the gravitational effects on pulmonary blood flow is the result of → _______(5) in the bases.
• You sit the patient up to help them breath and they actually get worse!

Answer 39

Answers:
1. Hypoxemia
2. 15mmHg
3. 15
4. platypnea-orthodeoxia
5. intrapulmonary vascular dilation
6. Arterial
7. Hypertension
8. pulmonary vascular dilatations
9. standing
10. supine
11. left
12. four

Question 40

Hepatorenal Syndrome

Defined as:
- Acute, reversible kidney failure due to end-stage liver disease
- Impaired renal blood flow and intense vasoconstriction

Causes:
- _______(1) vasodilation and _______(2) systemic resistance in liver failure
- → Decreased effective arterial blood volume
- → Activation of _______(3)-angiotensin and sympathetic nervous systems
- → Intense renal vasoconstriction

Liver failure can profoundly impact the kidneys and renal function in several ways:
- Toxins build-up: The liver normally filters toxins and byproducts from the blood. In liver failure, these accumulate and get deposited in the kidneys, damaging tissues.
- Decreased albumin production: The liver makes albumin and other proteins that maintain oncotic pressure to keep fluid in the bloodstream.
- Low albumin due to liver failure results in fluid leaking into the abdomen and kidneys.
- Electrolyte imbalances: The liver regulates electrolytes and minerals like sodium, potassium, and calcium. Abnormal electrolyte levels caused by liver failure can impair kidney function.

Answer 40

Answers:
1. Splanchnic
2. reduced
3. renin

Question 41

• Hypertension: Portal hypertension from liver damage increases pressure in the abdominal veins that drain to the liver. This backs up blood flow to the kidneys.
• Hepatorenal syndrome: This is acute kidney failure specific to end-stage liver disease. Diminished liver function reduces blood flow to the kidneys and causes functional impairment.
• Glomerular deposits: Immune complexes related to liver disease may deposit in the glomeruli of the kidneys, reducing their filtering capacity.
• _______(4) erythropoietin: The liver makes erythropoietin which stimulates red blood cell production. Lack of erythropoietin due to liver failure can cause anemia and reduce oxygen to kidneys.
• So in summary, liver failure allows toxins to accumulate, electrolyte imbalances to occur, and important proteins to decrease, all of which contribute to kidney dysfunction and renal insufficiency.
• Hepatorenal Syndrome
  
  • Here is a more in-depth look at hepatorenal syndrome in liver failure:
  • Definition: Hepatorenal syndrome is a form of acute, reversible kidney failure that occurs as a complication of end-stage liver disease. It is characterized by impaired renal blood flow and renal vasoconstriction.
  • Causes: In advanced liver failure, there is _______(5) vasodilation and _______(1) systemic vascular resistance. This leads to decreased _______(2) volume. To compensate, renin-angiotensin and sympathetic nervous systems activate, causing _______(3).

Answer 41

Answers:
1. reduced
2. effective arterial blood
3. intense renal vasoconstriction
4. Decreased
5. splanchnic

Question 42

Pathophysiology: Hepatorenal Syndrome

• Reduced glomerular filtration rate but structurally intact kidneys
• Diminished natriuresis, sodium retention, ascites
• Pathophysiology: The intense vasoconstriction causes functional renal failure by reducing glomerular filtration rate.
  
  • However, the kidneys are structurally intact.
  • There is also diminished natriuresis, _______(1) sodium retention, and ascites.
• Diagnosis: Based on acute kidney injury in chronic liver disease patient, absence of shock, no nephrotoxic drugs, bland urine sediment, _______(2) urine, _______(3) proteinuria. Imaging and biopsy can exclude other causes.
• Risk Factors: Alcoholic cirrhosis, viral hepatitis, NASH cirrhosis, refractory ascites, spontaneous bacterial peritonitis, hepatocellular carcinoma.

Answer 42

Answers:
1. increased
2. low sodium
3. no

Question 43

Box 33. 8 - Management of Hepatorenal Syndrome (HRS)

• Fluid restriction vs intravascular volume depletion, albumin, avoid nephrotoxins
• Vasoconstrictors, —6
• Liver transplantation (without: mortality >_______(1)%)
• Treatment: Fluid restriction vs intravascular volume depletion, avoid nephrotoxins (—5), albumin infusions, avoidance of nephrotoxic drugs, vasoconstrictors, midodrine, octreotide, norepi, liver transplantation.
• Prognosis: Mortality rate exceeds _______(2)% without _______(4). Hepatorenal syndrome can resolve if liver function improves or the patient receives a liver transplant.
• In summary, hepatorenal syndrome is a unique form of kidney failure driven by the pathophysiological changes of end-stage liver disease. Prompt diagnosis and management are key.
• The development of hepatorenal syndrome is an _______(3) sign and signals the need for immediate transplantation evaluation.

Answer 43

Answers:
1. 50
2. 50
3. ominous
4. liver transplant
5. NSAIDS, ARBS, ACEIs, ABX
6. midodrine, octreotide, norepinephrine

Question 44

Hepatic Encephalopathy

• Neurotoxins (ammonia) accumulate and alter neurotransmission via glutamate or altered cerebral energy homeostasis
• Mild apraxia&raquo_space; behavioral changes&raquo_space; decerebrate posturing&raquo_space; coma
• Poor metabolism of gut-produced ammonia vs intracranial bleeding
• Failure to metabolize vs failure to synthesize substances; shunting
• Trx: _______(1)
• Ammonia and its effect on _______(2) play a central role in the pathogenesis of HE.
  
  • Ammonia is a by-product of nitrogen-containing compounds that is toxic and must be removed from the body.
• The liver is the primary site of ammonia metabolism and excretion via the urea cycle, but the brain, skeletal muscle, and possibly kidneys contribute as well.
  
  • Unfortunately, neither the brain nor the skeletal muscle is capable of utilizing the urea cycle and instead use _______(3) synthetase to synthesize glutamine from ammonia and glutamate.
• Astrocytes are major constituents of the blood–brain barrier and are the primary location for glutamine synthetase in the brain.
  
  • Because these are the cells capable of metabolizing ammonia, as ammonia levels rise intracellular levels of glutamine rise in concert.
• There are two consequences to this:
  
  • (1) Glutamine, which is osmotically active, pulls water intracellularly, causing astrocyte swelling and cerebral _______(4).
  • (2) Glutamate, which is an important excitatory neurotransmitter, is first released and then consumed in producing glutamine.
• The manifestations of hepatic encephalopathy range from mild apraxia and behavioral changes to decerebrate posturing and coma.
• The actual pathophysiology of these changes is poorly understood but is thought to be related to poor metabolism of gut-produced ammonia and other byproducts.
• Treatment includes _______(5), which are thought to reduce encephalopathy by affecting bacterial function in the colon, thus reducing enteric ammonia production.

nonabsorbable disaccharides examples (lacitol and lactulose)

Answer 44

Answers:
1. Nonabsorbable disaccharides
2. astrocytes
3. glutamine
4. edema
5. nonabsorbable disaccharides,

Question 45

Liver Transplantation
- Liver transplantation is the sole definitive treatment modality for patients with acute liver failure, _______(1), and primary hepatic malignancy.
- The _______(2) (MELD) score is a validated system that UNOS uses for prioritizing patients on the liver transplant waiting list.
- The MELD score is a validated system that uses serum total bilirubin, serum creatinine, and the _______(3) values to mathematically rank adult patients according to their expected survival rate without transplantation.
- Occurs in _______(4) phases.
- Occurs in 3 phases
- The etiology of ESLD can be categorized into seven primary categories (Table 41.3).
Her tables are wrong like WTF

Answer 45

Answers:
1. ESLD
2. Model for End-Stage Liver Disease
3. INR
4. 3

Question 46

Liver Transplantation

Signs and symptoms:
- Anorexia, weakness, nausea, vomiting, abdominal pain, hepatosplenomegaly, ascites, jaundice, metabolic encephalopathy, spider nevi.
- Ascites: aspiration of fluid may see big hemodynamic shifts
- Cardiovascular: high cardiac output, high HR, low SVR, decreased RBF, extensive collaterals (esp lungs)
- Portal hypertension: ascites, esophageal varices; hepatic encephalopathy
- Pulmonary: V/Q mismatch
- Ascites: need volume expanders (albumin), Na restrictions and slow diuresis
- Renal dysfunction: no Na or free water secretion, vasoconstricts and causes sympathetic release
- High extravascular fluids
- Esophageal varices: vasopressin, RSI intubation
- Liver disease can have significant cardiac comorbidities and needs an in-depth cardiopulmonary _______(1).
- The cardiac exam should include transthoracic echocardiography, 12-lead ECG, and noninvasive cardiac stress testing at a minimum.
- The 2013 practice guidelines from the American Association for the Study of Liver Diseases and the American Society of Transplantation recommend noninvasive stress (exercise or pharmacologic) testing for all pretransplantation patients.
- Due to the _______(3) levels of circulation of catecholamines and generalized increased sympathetic activation, these patients are characterized as having a _______(2) circulation, which can fool the anesthetist into assessing cardiac function as adequate.
- The _______(4) afterload can actually mask cardiac dysfunction, and care needs to be taken not to overlook cardiac disease in otherwise “normal”-looking patients.
- Cirrhotic patients with ESLD often suffer from cirrhotic cardiomyopathy.
- This is characterized by increased cardiac output and a compromised ventricular response to stress.
- Cardiac performance declines, and the patient begins to suffer both diastolic and systolic dysfunction due to the activation of the cardiac renin-angiotensin system and impairment of the β-adrenergic receptor.
- This can have a great impact on anesthetic management and precipitate intraoperative hypotension that would respond poorly to increased catecholamine administration.

Answer 46

Answers:
1. screening
2. hyperdynamic
3. increased
4. decreased

Question 47

ESRD

Standard monitors
- A-line, large-bore IV access, CVC, PAC, cardiac output monitoring, POC ABGs, thromboelastogram (TEG), TEE, cell saver, rapid infuser, blood products (RBCs, FFPs, platelets, cryo)
- _______(1) is gold standard in hemodynamic monitoring
- Transfer to ICU on vent
- In preparing the operating room for surgery, the anesthetist should have standard monitors, in addition to planning for an arterial line, large-bore IV access, central venous catheter, PAC, continuous invasive or noninvasive cardiac output/function monitoring, thromboelastogram (TEG), TEE, cell saver, rapid infuser devices, blood products in the operating room or immediately available (RBCs, fresh frozen plasma [FFP], platelets, and cryoprecipitate), and transfer to the ICU on mechanical ventilation afterward.
- _________(2) is the gold standard in hemodynamic monitoring during liver transplantation to which other monitors are compared

Answer 47

Answers:
1. Pulmonary Artery Catheter
2. PAC

Question 48

Intraoperative management (ESLD)

• Normovolemia
• Coagulopathy: hyper- or hypocoagulable
• Temperature: keep warm
• Limited sedation
• No contraindications to induction agents
• Muscle relaxants
• Opioid of choice
• Post-induction hypotension
• Altered pharmacokinetic and pharmacodynamic response
• ICP monitoring
• It is prudent to _______(1) the amount of sedative premedication, as patients with liver disease are particularly sensitive to it.
• There are no absolute contraindications to induction agents, and the anesthetist may choose midazolam, ketamine, propofol, or etomidate.
• You may find it contraindicated to utilize _______(2) or rocuronium for a liver transplant (why?)
  
  • however it is acceptable because of the length and high likelihood for prolonged recovery of mechanical ventilation in the ICU.
  • Which other medication can you use for muscle relaxation?
    
    • _______(3) which undergoes Hoffman elimination is also an appropriate relaxant as it is not dependent on hepatic clearance.

Answer 48

Answers:
1. limit
2. vecuronium
3. Cisatracurium

Question 49

Intraoperative management (ESLD)

• Fentanyl, sufentanil, remifentanil, and alfentanil have all been used successfully.
• Due to the reduced peripheral vascular resistance seen in patients with ESLD, it is common to encounter post induction hypotension.
  
  • Vasopressors such as _______(1) are preferred for their α-adrenergic receptor specificity in the presence of an already hyperdynamic heart.
    
    • Another vasopressor that should be immediately available is _______(2).
      
      • Due to its potent vasoconstricting ability, a vasopressin infusion during induction, and possibly in combination with a phenylephrine infusion and boluses, can help provide a stable MAP and ensure adequate organ perfusion.
      • Any drugs primarily metabolized by the liver and cytochrome P-450 pathways will exhibit an altered pharmacokinetic and pharmacodynamic response in the ESLD patient.
• Intraoperative neurological monitoring is crucial for patients with liver disease because they are at risk for a large range of neurological complications including cerebral edema, encephalopathy, seizures, hypoxia, and central pontine myelinolysis.
• _________(4) ICP is especially common in patients with acute liver failure. This can be complicated by an increase in cerebral blood flow following hepatic reperfusion and thus higher ICP.
• It was shown that severe post transplant brain injury occurred at a rate of _______(3)% and was associated with severe pre transplant cerebral edema and a higher post transplant INR.
  
  • However the placement of an ICP monitor is a risk versus benefit analysis, and the placement of it did not show any significant benefit.

Answer 49

Answers:
1. phenylephrine
2. vasopressin
3. 7.8
4. increased

Question 50

Diseases of the Biliary Tract

• The biliary tract is the excretory conduit for the liver.
• It is composed of
  
  • (1) the intrahepatic ducts, which collect bile from the liver segments;
  • (2) the coalescence of the intrahepatic ducts and the right and left hepatic ducts
  • (3) the common hepatic duct, which is formed by the junction of the right and left hepatic ducts in the liver _______(1)
  • (4) the gallbladder, which serves as a ________(5) reservoir
  • (5) the _______(2), which joins the gallbladder to the CBD
  • (6) the CBD, which begins at the junction of the cystic duct and the common hepatic duct and terminates in the lumen of the _______(3).
• Arterial blood supply from the cystic artery from a branch of the hepatic artery.
  
  • This is the Artery They Clip in a Lap Chole; if they fail, this is where they’ll bleed
• Suppression or cessation of bile flow
• Most common cause of cholestasis is obstruction of biliary tract _______(4) of the liver
• Gallstones, stricture, tumor, infection, or ischemia

Answer 50

Answers:
1. hilum
2. cystic duct
3. duodenum
4. outside
5. bile

Question 51

Cholecystitis
- Caused by obstruction, infection, or both
- Acute cholecystitis usually related to _______(1) 90-95% of the time
- S/S include sudden _______(2) tenderness, fever and leukocytosis
- ________(5) – Murphy sign
- Jaundice – complete obstruction of cystic duct
- Charcot’s triad- ________(6), _______(3), RUQ pain

Contraindications to a lap cholecystectomy
- _______(4)
- _______(7)
- _______(8)
- _______(9)

Answer 51

Answers:
1. gallstones
2. right upper quadrant
3. jaundice
4. Coagulopathy
5. Inspiratory efforts worsen pain
6. fever/chills
7. severe COPD
8. ESLD
9. CHF

Question 52

Other Assoiciated Gastric Issues

Insufflation
- Decreased FRC, CC and increased PIP, hypotension
- 15 mmHg routine, the higher mmHg the great decreases in CO and _______(1)
- Increased risk of gastric _______(2)

Reverse Trendelenburg
- _______(3) venous return

Achalasia:
- Impaired _______(4) of LES
- a condition in which the muscles of the lower part of the esophagus fail to _______(7), preventing food from passing into the stomach.
- Chronic achalasia results in _______(5) of esophagus, more food and fluids retained- aspiration risk

GERD
- Failure of antireflux barriers
- Can manifest as ENT or pulmonary symptoms
- Chronic GERD can result in abnormal _______(6) cells and predisposition to developing a _______(8)

Answer 52

Answers:
1. PreLoad
2. reflux
3. Decreases
4. relaxation
5. dilation
6. epithelial
7. relax
8. malignancy

Question 53

GERD

Hiatal Hernia: Three types of hiatal hernia.
- (A) Type 1, or sliding hernia.
- (B) Type 2, or rolling hernia.
- (C) Type 3, or mixed hernia.
Aspiration prophylaxis
- RSI with cricoid pressure:
- LMA controversial
Surgical approaches to reduce incorrect hiatal hernias include laparoscopic Nissan _______(1).
________(4) may be superior to Nissan fundoplication for select patients with _______(2).
Anesthetic management includes
- aspiration prophylaxis, as discussed previously.
- Application of cricoid pressure has been shown to decrease lower esophageal sphincter.
- However normal gastric pressures remain.
- Consequently the value of cricoid cartilage pressure in rapid sequence induction has been questioned, although it remains a frequent technique in clinical practice.
Which commonly used gastro kinetic agent increases lower esophageal sphincter tone?
- Most likely _______(3) (metoclopramide) – young/naive stomach

Answer 53

Answers:
1. fundoplication
2. Barrett’s esophagus
3. Reglan
4. Elongation gastroplasty

Question 54

Anesthesia for Esophageal Disorders
- Asymptomatic vs uncontrolled disease with reflux symptoms
- Aspiration prophylaxis during induction and emergence
- Modification of gastric acidity with preoperative medications
- LMA?
- Special considerations may be necessary for patients with active esophageal disease.
- Occult disease (asymptomatic) is generally less concerning than uncontrolled disease states that manifest with reflux symptoms.
- A preoperative history of symptoms that indicate the presence of gastric reflux warrants aspiration prophylaxis during general anesthesia induction and emergence.
- Although best practice data do not support a specific regimen, modifying the acidity and/or volume of gastric contents remains a common preoperative practice.
- For maximum benefit, it is imperative to have an understanding of the pharmacokinetic/pharmacodynamic profile of selected preoperative medications.

• Rapid sequence induction with cricoid pressure may serve to hasten protection of the airway with a cuffed endotracheal tube (ETT) and limit opportunity for aspiration of gastric contents.
• Usage of a laryngeal mask airway (LMA) remains controversial in patients with active reflux disease.
  
  • The absence of definitive airway protection with LMA must be carefully considered, and a reasonable indication against endotracheal intubation should be present prior to implementation.
  • Poll Everywhere for medication to reduce stomach acidity

Peptic Ulcer Disease
- Gastric ulcer is loss of _______(1) due to inflammation.
- Approx 98% of peptic ulcer occur in the stomach and duodenum
- ________(5) infection is associated with development of 90% of duodenal ulcers and roughly _______(2) gastric ulcers
- Common complications include:
- Hemorrhage
- Perforation
- Obstruction

Gastritis
- Inflammatory disorder of gastric _______(3)
- Stress ulceration, stress erosive gastritis, and hemorrhagic gastritis
- Hemorrhagic gastritis can be life-threatening
- Upper GI bleed needs treatment
- RSI, Blood? Platelets? FFP?
- ________(6) inhibitors, H2 receptor antagonist
- PPI-________(7)
- H2 _______(4)
- Site question: Why do we commonly give these medications in our anesthesia management?

Answer 54

Answers:
1. mucosa
2. 75%
3. mucosa
4. Zantac and Pepcid
5. H. Pylori
6. Protein pump
7. protonix, nexium, Prevacid, prilosec

Question 55

Gastric Ulcer Disease
- Develop from degeneration of stomach’s mucosal barrier against gastric acid
- Pain and anorexia predispose pt to wt loss and metabolic changes
- Most common complication is _______(1)
- Most occur in _______(2) aspect of _______(4) curvature

Gastric Neoplastic Disease
- Gastric cancer 2nd most common cancer worldwide
- 7th most in U.S.

S/S include
- pain (constant, non-radiating and not relieved by food), wt loss, anorexia, fatigue, and vomiting
- _______(3) or partial gastrectomy (resection of tumor) remains the primary curative treatment

Answer 55

Answers:
1. perforation
2. anterior
3. Gastrectomy
4. lesser

Question 56

Gastric Surgery

Anesthetic Considerations
- Many procedures are laparoscopic
- Pts are usually acutely ill
- Consider _______(1), _______(2), usually anemic
- Lab
- Large IVs
- T/C, have products available
- Consider _______(3) for post-op pain management

Intestines
- Splanchnic blood flow
- The autonomic nervous system and the stress response.
- Mesentery is rich in lymphatic vessels and blood vessels.
- _______(4) adrenergic agonists vasoconstricts.
- ________(7) decreases blood flow to splanchnic system
- Both divisions of the autonomic nervous system innervate the small intestine, but innervation is primarily _______(5) through the vagus nerve and celiac ganglia.
- Parasympathetic stimulation is responsible for pain sensation, increased motility, secretion, and intestinal reflexes.
- Splanchnic nerves from the ________(8) provide sympathetic innervation
- Activation of these nerves _______(6) motility and produces vasoconstriction.
- Sympathetic nerve tracts are also responsible for carrying ________(9) pain impulses.
- DNP project: gum chewing pre- and post-op; prevention of ileus
- mesenteric traction syndrome is associated with a ________(10) in blood pressure and SVR, tachycardia, ________(11) cardiac output, and facial flushing.
- Think primarily parasympathetic

Answer 56

Answers:
1. volume
2. albumin
3. epidural
4. Alpha1
5. parasympathetic
6. inhibits
7. Neostigmine
8. celiac plexus
9. afferent
10. decrease
11. increase

Question 57

Anastomotic leakage
- Risk factors: anemias, co-morbidities, diabetics, vascular disease, decreased perfusion

Postoperative ileus
- Risk factors: pain, anesthesia, manipulation of bowel contents, unbalanced electrolytes, immobility, intestinal wall swelling from IV fluids
- prevention: start _______(1) feeds as early as possible, early ambulation, minimize bowel manipulation

Mesenteric traction syndrome
- tachycardia and hypotension
- txt _______(2)

Answer 57

Answers:
1. PO
2. antihistamine and NSAIDS

Question 58

Abdominal Compartment Syndrome
- Greater than _______(1) HG intraabdominal pressure; normal pressure is less than _______(2) HG
- Measured with a _______(3)
- Organ dysfunction develops if longer than _______(4); can lead to death

• abdominal trauma, hemoperitoneum, mesenteric arterial thrombosis, acute pancreatitis, intestinal obstruction, visceral edema, and massive fluid volume replacement
• Resuscitative efforts & exposure of the abdomen induce mesenteric edema formation and bowel dilation; delay closure until tension is resolved

Answer 58

Answers:
1. 20mm
2. 10mm
3. bladder manometer
4. six hours

Question 59

Abdominal Compartment Syndrome

Notes
- So think of your trauma patient. They come in with a motor vehicle accident and their abdomen is severely bruised and maybe an investigative laparotomy is performed in order to assess any damage to internal organs such as spleen and liver.
- The trauma to the abdomen and intestines is great. If your surgeon decides to close the abdomen at this time what you might see is a
- decrease in cardiac preload because of decreased venous return and elevated _______(1)
- elevated intrathoracic pressure
- reflex tachycardia and intracranial filling pressures are increased
- decreased thoracic compliance and decreased lung volumes result from impaired _______(2) descent.
- → Leading to increased pulmonary shunt fraction, atelectasis, and pulmonary edema; impairment in renal function results from compression of the kidneys and diminish perfusion.
- The end consequence is multiple organ failure.
- When you see these patients in the hospital, you may see them come back to the OR multiple times. Because of their prolonged course on a vent, _______(3) may develop and it is important that you try to match ventilator settings when you bring them back for their follow up procedures.
- —-6 syndrome is a serious but rare complication of surgical decompression in which the patient develops severe hypotension and acidosis immediately after the abdomen is decompressed
- it is due to a result of the release of acidotic blood from the mesenteric beds.
- ________(5) washout of the byproducts of anaerobic metabolism releases an array of cardiac depressants and vasodilatory mediators into the general circulation.
- Be ready, and make sure to increase your intravascular volume, have albumin ready, vasopressors, might need a POC blood gas machine available, and increase your ventilatory rate to blow off high CO2 levels.
- Mortality rate can be as high as _______(4)%.

Answer 59

Answers:
1. SVR
2. diaphragmatic
3. ARDS
4. 42
5. Reperfusion
6. Reperfusion

Question 60

Carcinoid Tumors
- Benign, slow growing
- Symptoms related to space occupying
- Usually originates in the GI tract
- Usually asymptomatic
- Can be metastatic
- Hormones released are metabolized by the liver
- _______(1), _______(2), kinin peptides

Answer 60

Answers:
1. Serotonin
2. histamine

Question 61

Carcinoid Syndrome
- Systemic effects:
- Flushing
- Bronchoconstriction
- Hypotension
- Hypertension
- Diarrhea (_______(1))
- life-threatening perioperative hemodynamic instability
- Carcinoid heart disease
- _______(2) sided cardiac involvement
- _______(3) and pulmonary valves
- Tumors along valves
- Bronchoconstriction
- Metastasized by the _______(4)
- Treatment: _______(5)
- Treatment: surgical excision, no chemo
- _______(5): can be given IV; somatostatin
- Stress reduction: Carcinoid crisis
- Avoid medications that increase release of hormones and mediators from tumor cells
- Histamine steroid sedation
- Anesthetic plan: treat HypoTN with fluids and octreotide, no _______(6), Zofran,
- Aline, CVP, ?PA cath, ICU, pain control post-op
- Carcinoid crisis: can necrose and release massive amounts of substances into circulations
- Avoid meds that will release _______(7)

Answer 61

Answers:
1. Serotonin
2. Right
3. Tricuspid
4. lungs
5. Octreotide
6. ephedrine
7. histamine

Question 62

Pancreatic Disease
- - Exocrine digestive enzyme and endocrine hormonal capacity
- Continuous secretion of 2.5 L of color, colorless, bicarbonate rich pancreatic juices (pH 8.3); main function duodenal _______(1)
- Endocrine functional cells reside in the _______(2)
- Alpha cells secrete _______(3); Beta cells secrete ________(6)
- Alpha-adrenergic sympathetic stimulation _______(4) insulin secretion
- Beta-adrenergic sympathetic and Cholinergic blockade also _______(4) insulin secretion
- Insulin suppression from
- Arterial hypoxemia
- Hypothermia
- Traumatic stress
- Surgical stress
- Insulin secretion is enhanced by
- _______(7) vagal stimulation
- _______(5) sympathetic activation
- _______(8) drug administration

Answer 62

Answers:
1. alkalization
2. islets of Langerhans
3. glucagon
4. inhibits
5. Beta adrenergic
6. insulin
7. Parasympathetic
8. Cholinergic

Question 63

Acute Pancreatitis
- Causes include alcohol abuse, trauma, ulcerative penetration, infection, vascular, metabolic disorders, autoimmune
- 80% of pancreatic disorder from _______(1) and _______(2)
- S/S include
- Abdominal distention
- N/V
- Pain
- _______(3)Bp?
- _______(4) vol?

Answer 63

Answers:
1. alcohol
2. gallstones
3. Hypotension
4. Hypovolemia

Question 64

Severe Acute Pancreatitis (SAP)
- SAP associated with organ failure, local complications, prolonged ICU and 25% mortality rate
- _______(1) dysfunction is main cause of death

Pain
- Difficult to control pain from pancreatitis
- Will I need narcotics, Morphine?, epidural analgesia
- Pain radiates from midepigastric to periumbilical, can be worse in _______(2) position

Anesthetic Considerations
- Fluids and electrolytes resuscitation is imperative
- Monitor labs
- C-reactive Protein (CRP) > _______(3) correlates with severity
- ASA standard monitors, large IVs, consider CVP and A-line
- Caution with medications that undergo hepatic biotransformation

Chronic Pancreatitis
- _______(4) and irreversible damage to the pancreas
- Chronic inflammation, fibrosis, destruction of exocrine and endocrine tissue
- Most common etiology is _______(5)-70% of cases

S/S
- Abdominal pain
- Wt loss
- Malnutrition
- Hepatic disease
- Predisposed to pericardial and pleural effusions
- _______(6)
- _______(7)

the normal C-reactive protein (CRP) value which is less than 10 mg/L

Answer 64

Answers:
1. Multiple Organ
2. supine
3. 150mg/L
4. Permanent
5. alcohol
6. Hypoalbuminemia
7. Hypomagnesemia

Question 65

Pancreatic Tumors
- Pancreatic cancer _______(1) ductal adenocarcinomas
- Can grow extensively before they produce symptoms
- Generally resected by pancreaticoduodenectomy (Whipple)

S/S
- Painless _______(2)
- Dull aching _______(3) or back pain
- Anorexia
- Fatigue
- New-onset _______(4) is occasionally the 1st symptom

Insulinoma
most common functioning tumor of the pancreas
- _______(5)
- _______(6)
- _______(7) (symptoms of catecholamine release)

Diagnostic Hallmark- Whipple triad
1. _______(5) (catecholamine release)
2.Low blood glucose (_______(8) mg/dl)
3.Relief after IV administration of _______(9)

Answer 65

Answers:
1. 80-90%
2. jaundice
3. midepigastric
4. DM
5. Hypoglycemia
6. Seizures
7. Coma
8. 40-50
9. glucose

Question 66

Whipple Procedure

Input Passage:

• Labs
• IV access, consider CVP
• ALine
• RSI?
• Products available
• Fluid resuscitation
• Consider epidural for post-op pain management
• Possible post-op vent, ICU admission

Zollinger-Ellison syndrome (ZES)

• Neoplasm primary arising from _______(1)
• Releases over abundant quantities of _______(2)
• Leads to secretion of massive quantities of _______(3) from parietal cells
• Intractable _______(4) pain
• _______(5) therapy is effective for surgery for tumor removal
  
  • _______(6) Ett plan?
  • Electrolyte correction
  • Dehydration
  • N/V
  • Diarrhea
  • Consider A-line for frequent _______(7)/glucose monitoring
  • Maintain temp, normocarbia, renal function
  • _______(8) Decompression?

Answer 66

Answers:

1. duodenum
2. gastrin
3. Hydrochloric Acid
4. ulcer
5. Omeprazole
6. RSI
7. labs
8. NGT

Question 67

Splenic Disease

• Splenic blood flow _______(8) mL/min and arises from _______(1)
• Functions include blood filtering, maintenance of normal _______(2) and immune processing of blood-borne foreign antigens
• Abnormal blood cells from disease such as _______(3), thalassemia and spherocytosis removed by macrophages
  
  • Can lead to worsening anemia and symptomatic splenomegaly
• Pt undergoing splenectomy are at greater risk for post-op _______(4)
  
  • Spleen not essential for life
• Spleen is the most frequently injured _______(5) organ
  
  • _______(9) % of adults intra abd trauma
    
    • Damage to spleen is important- most vascular body organ, receiving _______(6) of the CO
• Injury to splenic artery can produce lethal _______(7)
  
  • If stable, can be done laparoscopic, in __________(10) position
  • Caution with respiratory function, possible rib fractures for injury
  • Unstable/emergency laparotomy in a trauma to examine all abd organs
• Labs, fluid resuscitation, blood products available

Answer 67

Answers:

1. splenic artery
2. erythrocytes
3. sickle cell disease
4. infection
5. abd
6. 25%
7. hemoperitoneum
8. 300
9. 25-60
10. lateral decubitus