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63 Cards in this Set
- Front
- Back
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What are the 5 steps to recognizing hepatobiliary disorders?
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1 - CS
2 - Lab Abnormalities (CBC, Chem, UA) 3- Liver Function Tests (Bile Acid, Ammonia) 4 - US 5 - Histology |
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IF bilirubin is high and icteric, do you need to check bile acids?
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no - they will be high too
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Hypoalbuminemia requires the loss of how much hepatic function?
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80%
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What are globulins doing with decreased hepatic function?
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alpha and beta - decreased
-gammaglobulins (immune) are increased because the liver is the reticuloendothelial system --> inflammatin |
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What hemostasis factors does the liver make?
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coagulation factors
fibrinogenn plasminiogen anticoagulants |
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Cholestasis leads to malasimilation of what vit?
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fat soluble
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Is microhepatica an important finding on US?
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yes (not on radiology)
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What primary disorders should you consider with liver enlargement?
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right sided congestive heart failure
hyperadrenocortisms systemic mycosis |
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Serum bilirubin must be greater than what for icterus to occur?
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>2.5-3.0
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What is cholestasis and how do you tell there is cholestasis in a dog?
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stagnation of bile
1- increased AP 2 - bilirubinuria 3 - bilirubinemia 4 - icterus |
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What is the difference between icterus in a dog and cat?
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cats produce less AP
-get bilirubinemia first because have a higher renal threshold for bilirubin |
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What type of bilirubin will be in the blood with anemia?
with hepatic icterus? |
unconjugated
conjugated |
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When dealing with icterus, what is the first thing you should rule out?
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anemia - PCV
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What three diseases are not rule outs for hepatic icterus?
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1 - PSS
2 - steroid hepatopathy 3 - infectious canine hepatitis |
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What is the AP/ALT ratio for:
-hepatic icterus -post-hepatic icterus |
- hepatic: 1:1
-post-hepatic: > 3:1 |
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Are bilie acids and bilirubin typically higher or lower with post-hepatic icterus?
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higher
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What is the diagnostic plan for post-hepatic icterus?
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1 - CBC, Chem, UA
2 - US 3- Coagulation profile - fat soluble vit. k def 4 - abdominal explore 5 - 3 view thoracic 6 - serum lipase/amylase |
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Ascites with a transudate will have the following values:
TP WBC |
TP < 3.5
WBC <5,000 |
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What are 2 reasons for ascites?
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portal hypertension (P=Fxr)
--increased F (retention of Na) --increased r (inflammation, fibrosis, infiltration) hypoalbuminemia -must be less than 1.5 g/dl |
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What is not included in the rule out for ascites as a result of liver disease?
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1 - PSS
2 - steroid hepatopathy 3 - hepatic lipidosis 4 - cholangiohepatitis |
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What happens to the NT with hepatoencephalopathy?
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-excitatory NT decreases
-inhibitory NT increase -false NT increase |
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What are the toxins assoicated with hepaticecephalopathy?
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AA
Ammonia Short Chain FA Mercaptans GABA endogenous benzodiazepines synerigism |
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How much ammonia is normally removed from the portal blood?
What type of ammonia crosses cell membranes? |
90%
- unionized NH3 (in alkalotic envi) -NH4 is trapped (in acidodic) |
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How do you prevent alkalosis and thus keep NH3 from being unionized and crossing the cells?
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keep K up
-with hypokalemia, K will leave the cell and H will go in |
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When should you consider doing an ammonia tolerance test?
What is normal? |
when fasting levels of ammonia are normal
-don't do it if abnormal -< 30% increase |
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What are the 9 treatments for hepatic encephalopathy?
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1 - treat hepatic disease
2 - glucose 3 - povidone iodine enema (solution) 4 - lactulose 5 - neomycin 6 - metronizole 7 - fluids 8 - amoxicillin 9 - H2 blockers |
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What is the treatment for hepatic disease?
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-antibiotics, anti-inflammatory, immunosuppression
-vitamine E -milk thistle |
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Why would you give a povidone iodine enema (solution) for hepatic encepalopathy?
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-removes and kills colonic bacteria
- acidifies ammonia and traps it (favors NH4) |
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Why would you give lactulose for hepatic encepalopathy?
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-causes osmotic diarrhea
-acidifies ammonia and traps it -many puppies with PSS are often managed with lactulose, diet, and antibiotics |
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Is neomycin systemically absorbed?
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no
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Why should you be very careful when giving metronizole for hepatic encephalopathy?
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-systemic absorption and metabolized in the liver
-therefore increases the chance of hepatic toxicity |
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What H2 blocker do you NOT want to use when treating hepaticencephalopathy?
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cimitidine - inhibits P450 enzymes in the liver
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What does hypokalemia promote?
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alkalosis and renal production of ammonia
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What does pre-renal azotemia do?
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increases ammonia production
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What is the fluid of choice whrn treating liver disease?
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0.45% NaCl with 2.5% dextrose - isotonic fluid
-vigerous K supplementation -1/2 strength |
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What should the diet be with hepatic disease?
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-low protein (milk protein)
-highly digestable low fat -vit and min supplements - low salt -PD k/d, u/d -hills l/d Royal cancin LS14 |
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What is a result of the cascade of inflammation following an an initial insult with chronic active hepatitis?
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complement mediated cell lysis
-self perpetuating -hepatic insult --> release of antigens --> binding of antigen to hepatocyte --> release of hepatocyte specific antigens --> additional immune response |
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What does the liver look like with chronic active hepatitis?
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small, irregular, fibrosis (regenerative hyperpalsia)
-infliltration of plasma cells, lymphocytes, neutrophils -intrahepatic cholestasis -accumulation of copper and iron -portal hypertension and aquired PSS develop as a result |
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What will a biopsy tell you with chronic active hepatitis?
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if you can treat of not
fibrosis - can not treat |
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How do you treat chronic active hepatitis?
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1 - prednisone
2 - H2 blockers 3 - D-penicillamine 4 - Ursodexoxycholic acid (UD acid) |
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What will pred cause to increase when treating chronic active hepatitis?
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AP and ALT - therefore can no longer monitor via these enzymes
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Why do you treat chronic active hepatitis with D-penicillamine?
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1 - inhibits collagen synthesis
2 - inhibits cell mediated immunity 3 - decreased IgM and circulating immune complexes 4 - copper chelator - excreted in the urine |
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Why do you treat chronic active hepatitis with Ursodexoxycholic acid?
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1- hydrophlic bile acid
2 - cholerectic - stimulates bile flow by producing aqueous water and electrolytes (flushes things out of the liver) 3- hepatoprotectant - dissolves gallstones 4- requires long term terapy |
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What is elevated with steroid hepatopathy?
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-massive increase in AP
-increase in ALT -bile acids are usually normal, but can have abnormal and not showing CS |
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When do you reduce steroids with steroid hepatopathy?
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ONLY if showing CS (PU/PD, ect)
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What will liver look like on US with steroid hepatopathy?
What are the key features of this disease? |
- enlarged, uniform hyperechogenicity
-hydropic degeneration with centrilobular vacuolization |
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What is the end stage of many inflammatory hepatic diseases?
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cirrhosis
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What is a result of regenerative nodules?
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-compression of sinusoids and bile ducts and interference with flow
-portal hypertension--> hypoxia and cholestasis -PSS |
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What does cirrhosis of the liver look like on US?
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-increased superficial echogenicity
-decreased deep echogenicity |
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When treating cirrhosis o the liver, how do you arrest fibrogenesis?
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Cholchicine --> BLOCKS secretion of collagen in fibrous matrix, anti-inflammatory, direct hepatoprotectant
D-penicillamine |
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What is cholangiohepatis in cats?
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ascending infection form the GI tract that has moved from the bile duct to the liver
-supperative, plasmacytic, lymphocytic, biliary cirrhosis -associated with cholelits, cholecystists, IBD, pancreatitis |
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What enzyme is really increased with cholangiohepatitis?
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ALT
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How do you treat cholangiohepatisi in cats:
supperative non-supperative |
- supperative: antibiotics for 1-2 months (metro, amox, enro); remove obstruction, UD acid, treat IBD, pancreatitis
- non-supperative: pred, UD acid, diet |
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What is the most common type of hepatic neoplasia?
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metastasitc, malignant
-hepatocellular adenoma or carcinoma -biliary carcinoma -lymphoma |
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A clinical diagnosis of hepatic lipidosis requires how much percent of hepatocytes are filled with lipid?
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greater than 50%
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What primary disorders can lead to hepatic lipidosis in cats?
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-neoplasia
-renal disease -hyperthyroid -IBD -pancreatitis -diabetes mellitus |
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What will PE show on a cat with hepatic lipidosis?
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muscle wasting but preservation of the intra-abdominal fat pat
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What does a liver with hepatic lipidosis look like on US?
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diffusely hyperechoic compared to falciform fat, smooth borders, enlarged
-isoechogenic to omental fat -poor visualization of intrahepatic BV margins |
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What are common lab findings on a cat with hepatic lipidosis?
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-increased AP - a lot (other signs of cholestasis)
-increased ALT -anemia abnormal coag profile -Hyper: cholesterol Hypo: albumin |
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What test is diagnositic of hepatic lipidosis?
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FNA of the liver
-stain with oil red O for fat |
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What is the treatment for hepatic lipidosis?
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1 - fluids with K
2 - treat for hepatoencephalopathy 3 - feed - calories with high protein (PEG tube) 4- metocloprapide SQ |
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What is the feeding scheudle of a cat with hepatic encephalopathy?
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day 1 - feed 1/3 of maintenance (meals every 2-4 hours)
day 2 - feed 2/3 day 3- full -gradually increase the volume until can be fed in 3-4 feedings -offer food after 2 weeks of tube feeding |
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When can a PEG tube be removed in a cat with hepatic lipidosis?
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cat eats at least 75% of maintenance calories for 5 consecutive days
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