Bb Liver Disease

Front 1

How does the liver affect glucose homeostasis?

Back 1

formation, storage, and release of glucose by gluconeogenesis and glycogenolysis

Front 2

What is the half life of albumin and how does this affect acute liver dysfunction?

Back 2

23 days
-acute dysfunction will generally not decrease serum albumin levels

Front 3

With what levels of decreased albumin do you see increased drug sensitivty for drugs that bind to albumin?

Back 3

<2.5g/dL

Front 4

What is the cause of clotting deficiency with liver dysfunction?

Back 4

decreased factor production and vit K deficiency from lack of bile production

Front 5

Why do patients with liver dysfunction get thrombocytopenia?

Back 5

hepatosplenomegaly

Front 6

When do you see decreased cholinesterase activity in liver disease?

Back 6

prolonged and severe liver disease

Front 7

What hypotensive medication is contraindicated in severe liver disease?

Back 7

SNP

Front 8

What happens with impairment of bile production?

Back 8

steatorrhea and vit K deficiency

Front 9

What determines hepatic blood flow?

Back 9

HBF = perfusion pressure - splanchnic vascular resistance

Front 10

How do surgical incisions affect hepatic blood flow?

Back 10

surgical incisions decrease hepatic blood flow,
-the closer the surgical site to the liver, the greater the reduction in hepatic blood flow

Front 11

Albumin less than what level leads to ascites?

Back 11

<3.5 bc free water goes from an area of lower to higher oncotic pressure

Front 12

What is more specific for the diagnosis of liver disease ALT or prothrombin time?

Back 12

ALT

Front 13

What hepatitis virus is most commonly transmitted in blood transfusions?

Back 13

hepatitis B

Front 14

What are the pathologic changes to the liver with cirrhosis?

Back 14

liver parenchymal destruction with replacement by collagen

Front 15

what are physiologic changes associated with cirrhosis?

Back 15

1. hyperdynamic circulation leading to cardiomyopathy and CHF,
2. hypoxemia secondary to right to left intrapulmonary shunt,
3. hypoglycemia,
4. anemia secondary to GI bleeding an lack of folate due to malnutrition,
5. renal failure,
6. hepatic encephalopathy,
7. portal htn,
8. ascites

Front 16

Why is acute alcoholic hepatitis a contraindication to elective surgery?

Back 16

carries a 50% mortality weight

Front 17

Should you do surgery in patients with cirrhosis?

Back 17

not elective surgery

Front 18

What is the only nondepolarizer that undergoes significant liver metabolism?

Back 18

vecuronium

Front 19

Why should you be cautious of narcotics in patients with biliary dysfxn?

Back 19

choledochoduodenal sphincter spasm (incidence is very low)

Front 20

A patient with cirrhosis that is on sodium restriction preop, how should you manage their fluid intraop?

Back 20

preservation of intravascular volume and urine output take precedence intraop

Front 21

What are the major functions of the liver?

Back 21

1. glucose homeostasis
2. fat metabolism
3. protein synthesis
4. coagulation
5. cholinesterase activity
6. biotransformation of drugs
7. bilirubin excretion
8. bile excretion

Front 22

What are the causes of hypoglycemia in liver failure pts?

Back 22

1. insufficient insulin degradation by the liver
2. impaired glucose formation
3. glycogen depletion

Front 23

What is the only protein not produced in the liver?

Back 23

gamma globulin

Front 24

What is the major protein produced in the liver?

Back 24

albumin (normal 3.5-5.5)

Front 25

If albumin levels are decreased, what drugs will exist in plasma in less protein bound form and therefore are more pharmacologically active?

Back 25

1. barbs
2. midazolam
3. Coumadin

Front 26

What drugs are highly cleared by the liver on first pass metabolism?

Back 26

Mnemonic: "Bc Very Largely Metabolized, Dose Adjustment Down Is Needed"
B = beta blockers (propranolol, metoprolol labetolol)
V = verapamil
L = lidocaine
M = morphine, meperidine, midazolam
D = diltiazem
A = alfentanil, aminophylline
D = digoxin
I = imipramine
N = naloxone, nitroglycerin
-effects of these drugs are prolonged in liver failure

Front 27

All clotting factors except for which one is produced in the liver?

Back 27

All except for factor VIII

Front 28

Which factors have a short t1/2 and you will therefore see clotting abnormalities with acute and chronic liver failure?

Back 28

prothrombin
fibrinogen

Front 29

What is the plasma t1/2 of pseudocholinesterase?

Back 29

14 days

Front 30

Explain process of bilirubin formation and excretion.

Back 30

1. old RBCs are degraded by the spleen
2. globin is degraded into amino acids and the heme portion is degraded first into biliverdin and then into bilirubin
3. bilirubin is complexed to serum albumin and transported to the liver
4. liver cells conjugate the bilirubin with glucuronic acid, making it more soluble
5. bilirubin glucuronide can then be secreted into bile
- unconjugated bilirubin is the indirect fraction - increases result from liver parenchymal dz
- conjugated bilirubin is the direct fraction - increases in bilirubin obstruction

Front 31

What is the first pass effect?

Back 31

A phenomenon of drug metabolism whereby the concentration of a drug is greatly reduced befre it reaches the systemic circulation.
-first pass is the fraction of lost drug during the process of absroption which is generally related to the gut wall and liver

Front 32

Where are the 4 enzymes systems that effect first pass of a drug located?

Back 32

1. gastrointestinal lumen
2. gut wall
3. certain bacteria
4. liver

Front 33

What routes of admin avoid first pass metabolism?

Back 33

1. suppository
2. IV
3. IM
4. inhalational
5. sublingual
-these are absorbed directly into the systemic circulation

Front 34

How is the blood supply of the liver unique?

Back 34

It receives a dual blood supply
-portal vein 70%, hepatic artery 30% blood supply
-hepatic artery 55% of oxygen delivery

Front 35

What is the effect of volatile anesthetics on hepatic blood flow?

Back 35

All volatile anesthetics decrease HBF by decreasing hepatic perfusion pressure and increasing hepatic vascular resistance

Front 36

What is normal serum biliirubin?

Back 36

0.3-1.1
-unconjugated bilirubin 0.2-0.7 - can't be excreted by the kidneys
-direct bilirubin 0.1-0.4 - can be excreted

Front 37

At what level of bilirubin does jaundice occur?

Back 37

when bilirubin exceeds 3 mg

Front 38

If transaminases are ____ there is a high likelihood of acute hepatocellular damage.

Back 38

>3x normal

Front 39

Where can LDH be found?

Back 39

1. liver
2. heart
3. skeletal muscles
4. erythrocytes

Front 40

Which form of LDH is rather specific to the liver?

Back 40

isoenzyme-5 fraction

Front 41

what helps differentiate between biliary obstruction vs hepatocellular damage?

Back 41

Alk phos

Front 42

Hepatitis C infection results from what type virus?

Back 42

a single stranded RNA virus

Front 43

How can the diagnosis of HCV be confirmed?

Back 43

by the use of assay of HCV RNA and in some cases a supplemental recombinant immunoblot assay (RIBA) for anti HCV
-most RIBA + pts are potentially infectious as confirmed by PCR tests to detect HCV-RNA
-if a pt has anti HCV in serum confirmed by RIBA, without HCV RNA in serum, this suggests recovery from HCV in the past

Front 44

Describe the progression of Hepatitis C virus.

Back 44

-spans over several decades
-development of cirrhosis after about 30 years

Front 45

What factors lead to progression of Hep C?

Back 45

1. age older than 40 at the time of initial infection
2. daily alcohol intake >50 grams
3. male gender

Front 46

What is a treatment option for Hep C?

Back 46

Interferon normalized ALT and reduces inflammation
-thought to decrease viral replication and is better used with other antiviral drugs
-relapse is common after it is stopped

Front 47

What inhalational agent is preferred in liver failure?

Back 47

Isoflurane bc of its low liver metabolism

Front 48

What is the nondepolorizing agent of choice in liver failure?

Back 48

atracurium due to its spontaneous degradation at normal pH and temp (Hoffman elimination)

Front 49

Which is the volatile agent that produces fluoride in quantities associated with renal dysfunction?

Back 49

Methoxyflurane

Front 50

Is citrate toxicity more or less common in liver failure pts?

Back 50

more common due to its impaired metabolism

Front 51

How much bile does the liver make per day?

Back 51

about 1 liter