Week 13: Acute Hepatic Dysfunction Flashcards Preview

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Flashcards in Week 13: Acute Hepatic Dysfunction Deck (59):
1

what 3 criteria are found when a pt. has acute liver failure?

coagulopathy with an INR greater than 1.5

mental status change

loss of hepatic function

2

liver functions

-regulates most of chemical levels in blood

-excretes bile which helps carry away toxins

-break down of fat

-conversion of glycogen that can be used later for glucosea as energy (glycogen stored in live)

-regulation of many amino acids

-helps iron be incorporated into hemoglobin

-converts amonia to urea

3

liver enzymes

  • Alanine transaminase (ALT)(specific to liver itself): normal 5-35 U/mL, Increase  20X normal range trend in liver disease 
  • alt/ast ratio greater than 1: related to alcohol induces cirrohsis
  • alt/ast less than 1: acute hepatitis
  • aspartate aminotransferase (AST) (not specific to liver): normal 0-35 U/L, increased levels trend in liver disease
  • Alkaline Phosphatase (ALK Phos): normal 20-90 U/L, 2-3X increase with bile obstruction trend in liver disease

 

4

isoenzymes

  • lactate dehydrogenase (LDH): (Liver or muscle damage), LDH4- 8-16, LDH5- 6-16
  • alkaline phosphatase isoenzymes  (5-N) (hepatobiliary tissue), Less than 17 U/L
  • Gamma-glutamyl transpeptidase (GGT)(hepatobiliary, renal, and pancreatic tissues): 0-45 U/L

    *make sure pt. is fasting before we draw these

5

bilirubin

  • total:0.1- 1.2 mg/dL
  • direct:0.1- 1.0 mg/dL
  • indirect:0.1- 0.3 mg/dL
  • urobilirubin:Negative in fresh void urine
  • Jaundice when total bili levels above 2.5

6

Coagulation studies 

Liver produces

  • Prothrombin
  • Vitamin K
  • Help control the bleeding times
  • will see increased bleeding times

the higher the PT, the greater extend of liver damage.  Very prognostic

Partial Thromboplastin Time (PTT): Measures intrensic coagulation pathway

Prothrombin Time (PT): measure extrinsic coagulation pathways

7

 

Three causes of anemia in liver disease

  • potential blood loss
  • liver not properly forming RBC's
  • excessive distruction of the RBC's

 

 

8

Serum ammonia

  • Normal range 15-45 mcg/dL
  • Elevation indicates liver not converting ammonia to urea
  • Arterial levels a better indicator of true amonia levels

9

Serum albumin

  • Normal range 3.5- 5.0 g/dL
  • Synthesized by the liver
  • Decreases in liver disease
  • Poor indicator of acute liver disease d/t half-life of albumin (19-21 days)

 

 

10

acute hepatitis etiology, risk factors, clinical manifestations

Etiology

  • An inflammatory liver disease resulting in injury and necrosis
    • Less than 6 month duration
    • Hepatitis A-E
    • CMV
    • EBV
    • Drug Toxicity
    • ETOH abuse

Risk factors for HBV

  • Illicit drug use
  • Health care workers
  • Male homosexuals
  • Frequent blood transfusion
  • Decrease immune function
  • Sexual relations with HBV partners
  • Newborns of mothers with HBV

Clinical manifestations

  • Prodromal Period: Flulike symptoms
  • Jaundice
    • Anicteric hepatitis: inflammation of the liver d/t exposure from toxins and viruses
    • Cholestatic hepatitis: obstruction of bile ducts at gogi apparatus
  • Itching, pain upper right quadrant of abdomen, edema, coagulopathy

11

acute hepatic failure

*Inability of the liver to perform its normal functions


Results from:

  • Hepatic failure as a primary disease
  • Acute hepatic failure as a complication of chronic liver disease
  • Acute hepatic failure as part of multiple organ failure 

12

stages of hepatic encephalopathy

Stage I: Awake, apathetic, restless, sleep pattern changes, mental clouding diminished muscle coordination, mild to moderate EEG changes


Stage II: Decreased LOC, lethargy, drowsiness, asterixis, decreased reflexes, moderate to severe EEG changes


Stage III: Stupor (arousable), no spontaneous eye opening, hyperactive reflexes, seizures, rigidity, posturing- decorticate/ decerebrate severe EEG changes


Stage IV: Coma, seizures, pupil dialation, flaccidity, severe EEG changes

 

 

13

effects of hepatic failure on body systems

  • Neurologic: Stage I-IV encephalopathy
  • Cardiovascular: Pulmonary edema, hypotension
  • Gastrointestinal: N/V, constipation, diarrhea, anorexia, ascites
  • Hemtopioietic:  Impaired coagulation, prolonged PT
  • Pulmonary: Tachypnea, crackles 

14

esophageal varices

weakness in vasculature in the esophagus and stomach that associates with a pt. who develops portal htn.  Much more tender and easier to rupture

15

Complications of hepatic dysfunction hepatorenal syndrome

Type I HRS

Severe rapidly progressing renal failure.  Very high mortality rate.


Type II HRS
Slower, chronic, progressive (associated with a pt with ascites), does not improve with the use of diuretics

Clinical Characteristics

  • Prescience of liver failure
  • Decreased GFRazotemia
  • Oliguria/anuria
  • High BUN/Creatinine ratio
     

16

Complications of hepatic dysfunction: Infection

  • Kupper’s cells control inflammation and removal of gram-negative intestinal bacteria
  • Loss of protein synthesis
  • Both lead to increased risk of Sepsis and SIRS

 

17

collaborative management of pts with hepatic encephalopathy

  • Limit protein
  • Enema for constipation
  • Lactulose 15-30 ml for 3-5 stools per 24 hours
  • Neomycin 1-4g every 6-8 hours
  • Metronidazole 250 mg 3-4 times per day
  • Intubate and mechanically ventilate 

18

collaborative managmenet of pts with hypoglycemia and acute liver disease

  • 10% dextrose IV infusion
  • D5 IVP as needed for rapid recovery
  • POC blood glucose

19

collaborative management pts with metabolic abnormalities

  • Monitor electrolytes and pH
  • Correct abnormalities
  • Administer bicarb d/t acidodic states

20

Collaborative managemnet of acute liver disease pts: GI hemmorrhage

  • Administer Vit K
  • H2 receptor antagonists
  • FFP
  • Platelets 

21

collaborative managemnet: cerebral edema

  • ICP monitoring
  • Manitol
  • Hob 20-30 degrees
  • May need to be sedated with barbiturates

 

 

22

collaborative managment pts with hepatorenal syndrome

  • Liver transplant
  • Fluid resuscitation
  • TIPS shunt

23

collaborative management of spontaneous bacterial peritonitis

  • 3rd generation cephalosporin x 5-7 days
  • Monitor ascitic fluid for bacterial count

 

 

24

collaborative managmenet of esophageal verices

Control Bleeding

  • IV Vasopressin 20 U IVP followed by IV infusion 0.4-0.6 units per minute
  • Somatostatin  50 mcg/hr IV
  • Nitroglycerin
  • FFP

Correct Bleeding

  • Sengstaken-Blakemore placement
  • Portal systemic shunt surgery

Prevention

  • Betablockers
  • Mononitrates
  • Endoscopic sclerotherapy
  • Endoscopic variceal banding 

25

sentaken-blakemore placement

cause pressure to stop bleeding

A image thumb
26

normal anatomy of pancreas

  • both exocrine (most of cells in pancreas, produc and release pancreatic juice to digest fat, carbs, protein) and endocrine functions (much smaller in number, clusters of islets.  produce insulin (reduce amount of sugar in blood) and glucagon (increases sugar available in blood when bs is low))
  • neutralize chyme
  • digestive enzymes
  • hormones

27

pancreatic acinar cells 

  • specialized cells which synthesize, store, and secrete digestive enzymes
  • These digestive enzymes are stored in zymogen granules  which serve as a compartment for inactive pro-enzymes thus preventing auto-activation.

28

exocrine stimulation

  • The more proximal the nutrient infusion…the greater the pancreatic stimulation (dog studies)
    • stomach – maximal stimulation
    • duodenum – intermediate stimulation
    • jejunum – minimal / negligible stimulation
  • Elemental formulas tend to cause less stimulation than standard intact formulas
    • intact protein > oligopeptides > free amino acids
  • Intravenous nutrients (even lipids) do not appear to stimulate the pancreas

29

protective measures

  • COMPARTMENTALIZATION - digestive enzymes are contained within zymogen granules in acinar cells
  • REMOTE ACTIVATION - digestive enzymes are secreted as inactive proenzymes within the pancreas
  • PROTEASE INHIBITORS – trypsin inhibitor is secreted along with the proenzymes to suppress any premature enzyme activation
  • AUTO “SHUT-OFF” – trypsin destroys trypsin in high concentrations

30

acute pancreatitis

  • Acute inflammatory process involving the pancreas
  • Usually painful and self-limited
  • Isolated event or a recurring illness
  • Pancreatic function and morphology return to normal after (or between) attacks

etiology

  • usually due to gallstones or alcohol abuse
  •  

 

31

acute pancreatitis associated  conditions

  • Cholelithiasis
  • Ethanol abuse
  • Idiopathic
  • Medications
  • Hyperlipidemia
  • ERCP
  • Trauma
  • Pancreas divisum
  • Hereditary
  • Hypercalcemia
  • Viral infections: Mumps, Coxsackievirus
  • End-stage renal failure
  • Penetrating peptic ulcer

32

acute pancreatitis causative drugs

  • AIDS therapy: didanosine, pentamidine
  • Anti-inflammatory: sulindac, salicylates
  • Antimicrobials: metronidazole, sulfonamides, tetracycline, nitrofurantoin
  • Diuretics: furosemide, thiazides
  • IBD: sulfasalazine, mesalamine
  • Immunosuppressives: azathioprine, 6-mercaptopurine
  • Neuropsychiatric: valproic acid
  • Other: calcium, estrogen, tamoxifen, ACE-I

33

hereditary pancreatitis

  • Autosomal dominant with 80% phenotypic penetrance
  • Recurrent acute pancreatitis, chronic pancreatitis, and 50-fold increased risk of pancreatic cancer
  • Mutation in cationic trypsinogen gene (R122H)
  • Other genetic defects: CFTR, SPINK1

 

 

34

acute pancreatitis pathogenesis

  • acinar cell injury causes premature enzyme activation causing failed protective mechanisms-->autodigestion of pancreatic tissue-->local vascular issufficiency, activation of white blood cells, release of enxymes into the circulation-->local complications and distant organ failure
  • failure of compartmentalization, premature activation, and overwhelming or absence of inhibitors

35

stages of acute pancreatitis

  • STAGE 1: Pancreatic Injury
    • Edema
    • Inflammation
  • STAGE 2: Local Effects
    • Retroperitoneal edema
    • Ileus
  • STAGE 3: Systemic Complications
    • Hypotension/shock
    • Metabolic disturbances
    • Sepsis/organ failure

36

acute pancreatitis presentation

Abdominal pain

  • Epigastric
  • Radiates to the back
  • Worse in supine position

Nausea and vomiting

Fever

 


 

37

non hemorrhagic vs. hemorrhagic acute pancreatitis

non-hemorrhagic

  • Short duration
  • Pancreatic edema and swelling
  • Little to no necrosis
  • Local inflammation
  • Reversible
  • Good prognosis

 

hemorrhagic

  • Long duration
  • Pancreatic hemorrhage
  • Extensive necrosis
  • Extra-pancreatic
  • Irreversible damage
  • Poor prognosis- sepsis MOSF

 

38

acute pancreatitis diagnosis

Symptoms

  • Abdominal pain

Laboratory

  • Elevated amylase or lipase
    • > 3x upper limits of normal

Radiology

  • Abnormal sonogram or CT

 


 

39

causes of increased pancreatic enzymes

                                       amylase                       lipase

Pancreatitis                         ↑                                  ↑
Parotitis                                ↑                              Normal
Biliary stone                        ↑                                   ↑ 
Intestinal injury                   ↑                                   ↑
Tubo-ovarian disease       ↑                               Normal
Renal failure                        ↑                                  ↑
Macroamylasemia              ↑                               Normal

40

acute pancreatitis diagnosis

  • EtOH: history
  • Gallstones: abnormal LFTs & sonographic evidence of cholelithiasis
  • Hyperlipidemia: lipemic serum, Tri>1,000
  • Hypercalcemia: elevated Ca
  • Trauma: history
  • Medications: history, temporal association

 

 

41

acute pancreatitis clinical manifestations

PANCREATIC

  • Mild: edema, inflammation, fat necrosis
  • Severe: phlegmon, necrosis, hemorrhage, infection, abscess, fluid collections

PERIPANCREATIC

  • Retroperitoneum, perirenal spaces, mesocolon, omentum, and mediastinum
  • Adjacent viscera: ileus, obstruction, perforation

SYSTEMIC

  • Cardiovascular: hypotension
  • Pulmonary: pleural effusions, ARDS
  • Renal: acute tubular necrosis
  • Hematologic: disseminated intravascular coag.
  • Metabolic: hypocalcemia, hyperglycemia

42

acute pancreatitis time course

  • Cytokine release, 48 hrs, organ failure, 72 hrs
  • In the early stages ofpancreatic injury and inflammation, proinflammatory cytokines, such as interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor (TNF)-A, appear to be released from tissue macrophages within the pancreas.
  • Neutrophil activation likely results from release of IL-8 from macrophages and endothelial cells and release of platelet-activating factor (PAF) from endothelial cells.
  • Later in theprocess, release of cytokines from T-helper lymphocytes (eg, IL-2, interferon-C) may also participate in the inflammatory response [3]

 

 

43

predictors of severity of pancreatitis

Why are they needed?

  • appropriate patient triage & therapy 
  • compare results of studies of the impact of therapy

When are they needed?

  • optimally, within first 24 hours (damage control must begin early)

44

severity scoring system pancreatiis

Ranson and Glasgow Criteria (1974)

  • based on clinical & laboratory parameters
  • scored in first 24-48 hours of admission
  • poor positive predictors (better negative predictors)

Computed Tomography Severity Index

  • much better diagnostic and predictive tool
  • optimally useful at 48-96 hours after symptom onset

45

ranson criteria alcohol pancreatiis

At admission

  • Age > 55 years
  • WBC > 16,000
  • Glucose > 200
  • LDH > 350 IU/L
  • AST > 250 IU/L

 

Within 48 hours

  • HCT drop > 10
  • BUN > 5
  • Arterial PO2 < 60 mm Hg
  • Base deficit > 4 mEq/L
  • Serum Ca < 8
  • Fluid sequestration > 6L

higher point values=higher mortality rates

less than 2=1% mortality rate

3-4= 16%

5-6=40%

7-8=100%

 

46

glasgow criteria non-alcoholic pancreatitis

Glasgow prognostic score: (NOTE PANCREAS ACRONYM)

  • PaO2 < 8kPa (60mmhg)
  • Age > 55 years 
  • Neutrophils: (WBC >15 x109/l 
  • Calcium < 2mmol/l
  • Renal function: (Urea > 16mmol/l)
  • Enzymes: (AST/ALT > 200 iu/L or LDH > 600 iu/L)
  • Albumin < 32g/l 
  • Sugar: (Glucose >10mmol/L)

score > 8 points predicts 11% to 18% mortality

47

acute physiology and chronic health evaluation (apache II)

 

  • score > 8 points predicts 11% to 18% mortality
    •  Online calculator
  • Hemorrhagic peritoneal fluid
  • Obesity
  • Indicators of organ failure
  • Hypotension (SBP <90 mmHG)
  • tachycardia > 130 beat/min
  • PO2 <60 mmHg
  • Oliguria (<50 mL/h)
  • Increasing BUN and creatinine
  • Serum calcium < 1.90 mmol/L (<8.0 mg/dL)
  • serum albumin <33 g/L (<3.2.g/dL)

48

CT severity Index

looking at the results of looking at the pancreas itself, giving a grade and a score.  Best way to judge severity

appearance:

  • normal: grade A, score 0
  • enlarged:grade B, score 1
  • inflamed: grade c, score 3
  • 1 fluid collection: D, score 4
  • 2 or more collections: E, score 5 

Necrosis:

  • None: score 0
  • <33%: score 2
  • 33-50%: score 4
  • >50%: score 6

Score 1-2: 4% morbidity, 0% mortality

Score 7-10: 92% morbidity, 17% mortality

49

severe acute pancreatitis

Scoring systems

  • >/=3 Ranson criteria
  • >/=8 APACHE II points
  • >/= 5 CT points

Organ failure

  • shock (SBP < 90 mmHg)
  • pulmonary edema / ARDS (PaO2 < 60 mmHg)
  • renal failure (Cr > 2.0 mg/dl)

Local complications

  • fluid collections -->pseudocysts
  • necrosis (mortality 15% if sterile, 30-35% if infected)
  • abscess

50

assessment findings with pancreatitis

  • Anorexia
  • Abdominal rigidity/ tenderness
  • N/V
  • Pain – sudden, knifelike
  • Diminished/ absent Bowel sounds
  • Diminished breath sounds
  • Cullen’s sign: bruising around the umbilicus
  • Grey turner’s sign: flank bruising
  • Altered LOC
  • Chvostek’s sign: tapping in front of ear, mouth twitches
  • Trousseau’s sign:  latent tetany is a medical sign observed in patients with low calcium 
  • Non-cardiogenic pulmonary edema heard most often on Left side

 

 

51

treatment of mild pancreatitis 

  • Pancreatic rest
  • Supportive care
    • fluid resuscitation – watch BP and urine output
    • pain control
    • NG tubes and H2 blockers or PPIs are usually not helpful
  • Refeeding (usually 3 to 7 days)
    • bowel sounds present
    • patient is hungry
    • nearly pain-free (off IV narcotics)
    • amylase & lipase not very useful here

 

*mild panc – support is all that’s needed
*hypotension probably predisposes to necrosis (poor microcirculation)

52

treatment of severe pancreatitis

  • Pancreatic rest & supportive care
    • fluid resuscitation* – may require 5-10 liters/day
    • careful pulmonary & renal monitoring – ICU
    • maintain hematocrit of 26-30%
    • pain control – PCA pump Why Not Morphine?
    • correct electrolyte derangements (K+, Ca++, Mg++)
  • Rule-out necrosis
    • contrasted CT scan at 48-72 hours
    • prophylactic antibiotics if present
    • surgical debridement if infected
  • Nutritional support
    • may be NPO for weeks
    • TPN vs. enteral support (TEN)

53

Role of ERCP

Gallstone pancreatitis

  • Cholangitis
  • Obstructive jaundice

Recurrent acute pancreatitis

  • Structural abnormalities
  • Neoplasm
  • Bile sampling for microlithiasis

Sphincterotomy in patients not suitable for cholecystectomy

* Sedated, scope ran down through mouth to see what's going on 

54

nutrition in acute pancreatitis

Metabolic stress

  • catabolism & hypermetabolism seen in 2/3 of patients
  • similar to septic state (volume depletion may be a major early factor in the above derangements)

Altered substrate metabolism

  • increased cortisol & catecholamines
  • increased glucagon to insulin ratio
  • insulin resistance

Micronutrient alterations

  • calcium, magnesium, potassium, etc

55

systemic changes in acute pancreatitis

Hyperdynamic

  • Increased cardiac output
  • Decreased systemic vascular resistance
  • Increased oxygen consumption

Hypermetabolism

  • Increased resting energy expenditure

Catabolism

  • Increased proteolysis (breakdown) of skeletal muscle

56

reduce oral intake in acute pancreatitis

  • Abdominal pain with food aversion
  • Nausea and vomiting
  • Gastric atony ( decresed motility)
  • Ileus
  • Partial duodenal obstruction

57

Factors differentiating mild vs. severe pancreatitis

mild

  • Admission 80%
  • Pancreatitc Necrosis: No
  • Oral diet within 5 days: 80%
  • Morbidity: 8%
  • Mortality: 3%

Severe

Admission 20%
Pancreatitc Necrosis: Yes
Oral diet within 5 days: 0%
Morbidity: 38%
Mortality: 27%

58

TPN in acute pancreatitis

  • delay until volume repleted & electrolytes corrected
  • check triglycerides first – goal <400
  • lipids are OK to use (possible exception of sepsis)
  • monitor glucose levels carefully
    • can see insulin insufficiency and resistance
    • may need to limit calories at first
    • separate insulin drip may be needed

Benefit or harm?

  • early uncontrolled studies suggested benefit
  • two retrospective studies (70’s & 80’s) showed no benefit with TPN in pancreatitis
  • 1987 – randomized study of early TPN vs. IVF alone showed more sepsis, longer stays, & no fewer complications with TPN

When to use TPN?

  • jejunal access is unavailable
  • ileus prevents enteral feeding
  • patients in whom TEN clearly exacerbates pancreatitis

59

total enteral nutrition in severe pancreatitis

  • may start as early as possible
    • when emesis has resolved
    • ileus is not present
  • nasojejunal route preferred over nasoduodenal
  • likely decreases risk of infectious complications by reducing transmigration of colonic bacteria