Test 4 GI

Question 1

what is defined as the portal triad?

Answer 1

hepatic arteriole
portal venule
bile ductal

Question 2

microcirculation of the liver lobule is divided into ________ zones that receive varying oxygen content`

Answer 2

3

Question 3

zone 1 of liver lobule receives __________ blood from the __________ & ________

Answer 3

oxygen rich; adjacent portal vein and hepatic artery

Question 4

blood entering zone 3 of the liver lobule is _______________

Answer 4

oxygen poor

Question 5

what zone of the liver lobule is most affected by hypoxia and reactive metabolic intermediates?

Answer 5

zone 3

Question 6

liver synthesizes all clotting factors except ?

Answer 6

III, IV, and VIII

Question 7

Vitamin K dependent clotting factors are dependent on what function of the liver?

Answer 7

bile excretion

Question 8

blood coagulation fx of the liver

Answer 8

• synthesis of clotting factors (except III, IV, VIII)
• synthesis of pro and anti-clotting factors
• produces thrombopoietin

Question 9

liver receives __________% of CO via dual supply

Answer 9

25%

Question 10

how much bile is produced daily?

Answer 10

500ml

Question 11

the hepatic portal vein supplies 75% of the liver inflow, this is due to the ____________________ in the portal vein

Answer 11

low vascular resistance

Question 12

metabolism functions of the liver

Answer 12

• stores/releases glycogen/site of gluconeogenesis
• urea production (aa and protein metabolism)
• fatty acid, cholesterol, and plasma protein synthesis (lipid metabolism)

Question 13

T/F: endocrine abnormalities may be more common with liver disease

Answer 13

true

Question 14

endocrine management fx of liver

Answer 14

1. synthesizes and secretes: angiotensinogen, thrombopoietin, thyroid binding globulin
2. converts T4 to T3
3. inactivates corticosteroids, mineralcorticosteroids, and androgens

Question 15

in liver dysfunction there may be alterations that affect pharmacokinetics/dynamics of many anesthetic agents. This is because of what function of the kidney

Answer 15

protein synthesis

Question 16

what protein synthesized in the liver binds amide type local anesthetics, opoids, and propranolol

Answer 16

alpha-1 acid glycoprotein

Question 17

what protein synthesized in the liver metabolizes succinylcholine and ester local

Answer 17

pseudocholinesterase

Question 18

drug metabolism is primarily performed by what organ?

Answer 18

liver (hepatic)

Question 19

what is the goal of hepatic biotransformation within the liver

Answer 19

to make drugs inactive, water soluble, and ready to excrete

Question 20

phase 1 of hepatic biotransformation

Answer 20

oxidation, reduction, dealkylation, hydrolysis

Question 21

which phase of hepatic biotransformation is more susceptible to inhibition by advanced age and/or hepatic dysfunction?

Answer 21

phase 1

Question 22

phase 2 reaction of hepatic biotransformation

Answer 22

conjugation

Question 23

what is the first pass effect?

Answer 23

pre-systemic elimination of drugs delivered via the oral route

Question 24

what is the effect on high extraction rate drugs taken orally (lidocaine, propranolol, morphine) due to the first pass effect?

Answer 24

they will have reduced bioavailability due to the presystemic metabolism

Question 25

what is the effect on drugs with a low extraction rate (tegretol, valium, dilantin, procanamide, warfarin) if taken orally, due to the first pass effect?

Answer 25

will have minor first pass effects, but will have a slow metabolism and are more dependent on hepatic clearance

Question 26

if liver dysfucnction is known or suspected, what does this mean for your anesthetic agent plans perioperatively?

Answer 26

- unknown effects with kinetics and dynamics - need to weigh risk/benefit of comorbid conditions - CAREFUL TITRATION

Question 27

T/F: in the absence of a positive H&P or known liver disease preoperative lab testing is unnecessary

Answer 27

true

Question 28

what should you evaluate if a pt has a known hx or positive hx of liver dz prior to surgery?

Answer 28

1. eval hepatocyte injury/necrosis through ALT, AST, GST (liver fx tests) 2. eval hepatic conjugation and excretion (bilirubin) 3. eval hepatic excretion (alkaline phosphatase, GGT) 4. evaluate protein synthesis (Albumin, PT, INR)

Question 29

normal AST

Answer 29

10-40 IU/L

Question 30

normal ALT

Answer 30

10-60 IU/L

Question 31

what could a ALT of 180/AST of 120 indicate? (i.e. mildly elevated transaminases)

Answer 31

fatty liver non-etoh steatohepatitis drug toxicity chronic viral hepatitis

Question 32

mildly elevated ALT/AST (3x) normal would be ALT ____; AST ____

Answer 32

180; 120

Question 33

what is defined as a large increase in ALT & AST

Answer 33

4 - 22x normal (AST: 40-160 - 220-880)(ALT: 40-220 - 240-1320)

Question 34

an AST/ALT ratio of > 2 indicates

Answer 34

alcoholic liver disease

Question 35

an AST/ALT ratio of <1 indicates

Answer 35

viral hepatisis

Question 36

what do liver fx tests (AST/ALT) assess

Answer 36

hepatocyte cellular injury

Question 37

having ALT of 500 and AST of 700 would indicate?

Answer 37

1. acute hepatitis 2. chronic hepatitis exacerbation (etoh induced) 3. drug/toxin induced hepatocellular necrosis 4. severe hepatitis 5. ischemia hepatitis complicating circulatory shock

Question 38

bilirubin orginiates from _______________

Answer 38

breakdown of hemoglobin

Question 39

unconjugated bilirubin is the _________ soluble form; while conjugated is the ___________ soluble form

Answer 39

lipid; water

Question 40

normal value for unconjugated bilirubin

Answer 40

1-4 mg/dL

Question 41

elevated unconjugated bilirubin indicates?

Answer 41

disorder of bilirubin metabolism d/t either excess production of bilirubin through hemolysis or decrease in the uptake and conjugation of bilirubin by hepatocytes

Question 42

what does elevated conjugated bilirubin indicate?

Answer 42

1. impaired intrahepatic excretion or extrahepatic obstruction 2. could be d/t gall stones

Question 43

Bilirubin > 35 indicates

Answer 43

severe liver dz in association with hemolysis or renal failure

Question 44

T/F: serum albumin is a great indicator of acute liver disease

Answer 44

false; due to 3-week half life it is not a reliable indicator of acute liver dz

Question 45

other than in liver dz when may albumin levels be low?

Answer 45

enteropathy burns nephrotic syndrome

Question 46

albumin levels can be a significant indicator of what in regards to liver dz?

Answer 46

worsening fx of liver in chronic liver dz

Question 47

what labs are sensitive indicators of hepatic dz because of short half life?

Answer 47

PT and INR

Question 48

when might PT be prolonged in the absence of liver dz?

Answer 48

biliary obstruction congenital coagulation factor deficiencies DIC warfarin therapy

Question 49

what are the 3 types of alcoholic liver dz?

Answer 49

steatosis hepatitis cirrhosis

Question 50

which type of etoh liver dz is usually benign and will resolve with abstinence

Answer 50

steatosis