Bryan - La Medicine - Fall Yr 3 - Hepatic Dz And Endotoxemia

Front 1

Approximately how much cardiac output is directed toward the liver?

Back 1

25%

Front 2

Which of the following animals lacks a gallbladder?
a) horse
b) pig
c) camelid
d) cow
e) javelina
f) Sara!!

Back 2

a) horse
b) camelid
e) javelina
f) Sara!!

Front 3

What are the major hepatic functions?

Back 3

Carb metabolism
Fat metabolism
Protein metabolism
Detox
Bile acid synthesis
Urea synthesis

Front 4

What is the metabolic fate of cholesterol?

Back 4

BILE ACIDS

Front 5

Put the following in the correct order
Albumin/bilirubin
Biliverdin
Conjugated bilirubin
Heme
Hemoglobin
Urobilinogen
Uncongugated bilirubin

Back 5

Hemoglobin
Heme
Biliverdin
Uncongutated bilirubin
Albumin/bilirubin
Conjugated bilirubin
Urobilinogen

Front 6

What can cause increases in unconjugated bilirubin?

Back 6

Excess production (hemolysis)
Decreased uptake into liver
Disturbed protein binding
Disturbed conjugation

Front 7

What can cause increases in conjugated bilirubin?

Back 7

Disturbed secretion of CB
Intra/extrahepatic cholestasis

Front 8

What are common, fairly specific signs in hepatic failure?

Back 8

Jaundice/icterus
Photosensitization
Hepatic encephalopathy
(wt loss, colic, depression, anorexia are less specific)

Front 9

What is the pathogenesis of ventral edema in hepatic failure? Which species is this less common in?

Back 9

Low protein = edema
Hepatic fibrosis > portal hypertension > edema
Less common in horseses

Front 10

What compound causes photosensitization?

Back 10

Phylloerythrin

Front 11

What enzymes indicate hepatocellular damage in large animals? Which is mainly for ruminants and which for horses?

Back 11

AST, GLDH (ruminants), SDH (horses), LDH5
(note: ALT doesn't work well in large animals)

Front 12

What enzymes indicate cholestasis in large animals? How long do the induced enzymes take to peak?

Back 12

ALP, GGT
Take ~7d to peak

Front 13

Hypoalbuminemia is uncommon in what large animal species?

Back 13

Horses

Front 14

Bilirubinemia can be indicative of what conditions?

Back 14

Anorexia/fasting
Hemolysis
Early hepatic disease
Obstructive biliary disease

Front 15

What urine parameters can be indicative of hepatobiliary disease?

Back 15

High conjugated bilirubin = cholestasis
Increased urobilinogen = hemolysis or hepatocellular dz

Front 16

T or F:
Increased BUN can be indicative of hepatic dysfunction.

Back 16

False!
Altered NH3 metabolism = DECREASED BUN

Front 17

Serum bile acids greater than what values are indicative of liver disease in large animals? What conditions would cause the highest values?

Back 17

>15-20 umol/L
Greatest increases w/cholestasis and portal shunts

Front 18

Where can you pretty much always find the liver with ultrasound in a horse? In a cow?

Back 18

Horse - left 7 to 9th ICS
Cow - right 8 to 12th ICS

Front 19

How should a normal liver look on ultrasound as compared with the spleen? With the kidney?

Back 19

Liver is hypoechoic (darker) to the spleen and hyperechoic (lighter) to the kidney.

Front 20

What are liver biopsy landmarks for the horse? The cow?

Back 20

Horse - R side 12th ICS along line from tuber coxae to olecranon
Cow - 20-30cm to R of midline in 11 or 12th ICS

Front 21

What are poor prognostic indicators for hepatobiliary disease in horses?

Back 21

Hypoalbuminemia (<2.5g/dL)
Chronic hyperglobulinemia
PT>30% above normal
High GGT and ALP with low or normal SDH
Marked fibrosis
Hepatic encephalopathy
Hemolytic crisis
Bile Acids >50umol/L

Front 22

What occurs in the three acinar zones? Which has the highest/lowest O2 levels?

Back 22

Zone 1 - high O2; gluconeogenesis, oxidative metabolism
Zone 2 - mix of 1 and 2
Zone 3 - low O2; glycolysis, lipogenesis

Front 23

The most common cause of acute hepatitis/hepatic failure in horses is...

Back 23

...Theiler's Disease (idiopathic acute hepatitis)

Front 24

Idiopathic acute hepatitis is often associated with...

Back 24

...tetanus antitoxin
...plasma transfusion

Front 25

What is a common signalment for Theiler's disease?

Back 25

Adult (>2yo) lactating mare 1-3 months post foaling.

Front 26

What clinical sign is pathognomic for Theiler's disease?

Back 26

Nothing really! You will see a dishrag liver on necropsy though but that's not too clinical...

Front 27

What is the causative agent of Tyzzer's disease? What is the signalment of this disease?

Back 27

Clostridium piliformis
Foals <6wks

Front 28

How is Tyzzer's disease diagnosed?

Back 28

Usually post-mortem;
Demonstration of bacterium in liver (chinese characters);
Maybe PCR or FAb

Front 29

What is the common signalment of infectious necrotic hepatitis? What is the causative agent?

Back 29

Disease of sheep
Caused by Clostridium novyi type B

Front 30

Infectious necrotic hepatitis is nearly always associated with what other variables?

Back 30

Hepatic parasitism (F. hepatica)
Liver biopsy

Front 31

Compare infections by Clostridium novyi types B and D.

Back 31

Type B - Black Disease (Infectious Hepatic Necrosis); mostly sheep and sometimes horses; subcut hemorrhage; ubiquitous in distribution
Type D - Redwater (Bacillary hemoglobinuria); ruminants and occasionally horses; bleeding from orifices; more regional in distribution

Front 32

Clostridium novyi type D is also known as...

Back 32

...Clostridium haemolyticum (causes redwater or bacillary hemoglobinuria)

Front 33

What are most hepatic abscesses in cattle caused by? In goats?

Back 33

Fusobacterium necrophorum (cows)
Corynebacterium pseudotuberculosis (goats)

Front 34

T or F:
Due to their lack of a gallbladder, horses have a lower incidence of hepatic abscesses than do cattle.

Back 34

False! This just makes no sense! Its really due to rumenal bacteria crossing into the portal vein and lodging in the liver

Front 35

What laboratory values may be diagnostic for hepatic abscess in cattle?

Back 35

Reversed N:L ratio (normal is 40:60)
Increased fibrinogen and globulins
Elevated GGT and AST

Front 36

What are some important differentials when considering a hepatic abscess?

Back 36

Johne's disease
Traumatic reticuloperitonitis
Parasitism
Lymphosarcoma
Malnutrition

Front 37

What variable can increase chances in cattle to hepatic abscesses?

Back 37

Abrupt high grain diet

Front 38

What is the most common equine hepatic issue at the OSU large animal hospital? What is the signalment?

Back 38

Equine Herpesvirus 1;
affects foals

Front 39

When is the earliest that clinical signs will present after ingestion of Fasciola hepatica metacercariae? How long before they shed eggs?

Back 39

6-7 wks
2-4 wks after (8 - 11 wks total)

Front 40

What are the 3 syndromes of liver fluke disease? How many flukes are associated with each?

Back 40

Subclinical disease (<40 flukes)
Clinical disease (>200 flukes)
Acute illness/death (clostridial disease)

Front 41

T or F:
Cattle can clear Fasciola while sheep and goats often cannot.

Back 41

True!
After 5-6 months cattle mount an immune response and clear the infection.

Front 42

Fasciola hepatica eggs can be confused with...

Back 42

...Paramphistomum spp.; the rumen fluke

Front 43

How can liver flukes be treated in OR with one treatment?

Back 43

treat in late fall/early winter;
removes adults prior to onset of winter stress and prevents egg shedding

Front 44

Fascioloides magna infection has a high mortality in:
a) goats
b) sheep
c) deer
d) cattle

Back 44

goats and sheep

Front 45

Which liver fluke doesn't hurt sheep all that much...

Back 45

Dicrocoelium dendriticum (Lancet fluke)

Front 46

What is the fat composition threshold for hepatic pathology in cattle?

Back 46

>34% fat = pathology

Front 47

Which types of equids most commonly develop hyperlipemia or hyperlipidemia? What are these conditions associated with?

Back 47

Donkeys, ponies, and mini horses;
Associated with a sudden drop in dietary carbohydrates

Front 48

Choose hyperlipemia or hyperlipidemia...
...much worse clinically.

Back 48

hyperlipemia

Front 49

Choose hyperlipemia or hyperlipidemia...
...often presents with concurrent rhabdomyopathy.

Back 49

hyperlipemia

Front 50

Choose hyperlipemia or hyperlipidemia...
...associated with azotemia.

Back 50

hyperlipidemia

Front 51

Choose hyperlipemia or hyperlipidemia...
...white to yellow plasma.

Back 51

hyperlipemia

Front 52

Choose hyperlipemia or hyperlipidemia...
...sky high triglycerides

Back 52

hyperlipemia

Front 53

Administration of what hormone reduces fat mobilization?

Back 53

Insulin

Front 54

Chronic active hepatitis is characterized by what kind of infiltrate?

Back 54

Lymphocytic/Plasmacytic

Front 55

What are some fairly nasty-sounding clinical signs associated with chronic active hepatitis in horses?

Back 55

Moist exfoliative dermatits at the coronary band
Focal areas of necrotic leathery skin

Front 56

Which enzymes will be markedly high during chronic active hepatitis in a horse?
a) AST
b) ALT
c) GGT
d) SDH
e) GLDH

Back 56

ALP and GGT

Front 57

What histologic change denotes chronic active hepatitis?

Back 57

bridging necrosis and bridging fibrosis

Front 58

What feature characterizes suppurative cholangiohepatitis?

Back 58

Neutrophilic invasion of the hepatic portal tracts and bile ducts

Front 59

T or F:
Steroid-responsive lymphacytic/plasmacytic infiltrates in chronic active hepatitis provide a moderate prognosis.

Back 59

True!
Although steroids don't prolong survival so it confuses me why this is true...

Front 60

What type(s) of bacteria usually shows up in culture with suppurative cholangiohepatitis?

Back 60

Gram negative gut bacteria (salmonella, citrobacter, E. coli, aeromonas, actinobacter)

Front 61

The condition involving stones in the common bile duct is...
How about in the L or R bile ducts? Gallbladder? Intrahepatic duct?

Back 61

Choledocholithiasis (common)
Cholelithiasis (L, R or bladder)
Hepatolithiasis (intrahepatic)

Front 62

Which type of cholelith can horses not get?

Back 62

They get them all! More common in horses anyhow!

Front 63

What is the triad of signs indicating cholelithiasis? What is the common signalment?

Back 63

colic, pyexia, and icterus in horses >5yo

Front 64

What are fairly diagnostic biochemical values indicating cholelithiasis?

Back 64

Sky high ALP and GGT (15x normal)
Conjugated bilirubin >25% of total bilirubin

Front 65

What is a common site to view choleliths in horses via ultrasound?

Back 65

Cranioventral R lobe (6th to 8th ICS)

Front 66

What is the channel sign?

Back 66

distended intrahepatic bile duct running alongside the portal vein

Front 67

What toxin is most likely the most common cause of chronic liver disease in large animals?

Back 67

Pyrrolizodine alkaloids

Front 68

With regard to hepatic toxicity, megalocytosis is associated with which toxin?

Back 68

mycotoxins
Pyrrolizodine alkaloids too

Front 69

Describe the pathogenesis of pyrrolizodine alkaloids.

Back 69

PAs converted to pyrroles in the liver.
Pyrroles crosslink DNA, previnting mitosis, leading to megalocytic hepatopathy.
Cells die leading to fibrosis.

Front 70

What are the best methods for controlling behavior in cases of hepatic encephalopathy?

Back 70

Use alpha-2 agonists (avoid diazepam)
Treat acute hypoglycemia
Reduce blood ammonia

Front 71

When does Dr. McKenzie say that acidosis should be corrected with bicarb?

Back 71

At or below 7.1

Front 72

What are poor prognostic indicators when treating hepatic disease?

Back 72

Hemolysis
Hepatic encephalopathy
Severe acidosis
Diarrhea
Bridging necrosis/fibrosis on biopsy

Front 73

Sepsis is...

Back 73

...the systemic inflammatory response to infection.

Front 74

What is SIRS?

Back 74

Systemic inflammatory response syndrome

Front 75

What is endotoxemia?

Back 75

Endotoxemia refers to circulating LPS from gram negative bacteria cell walls.

Front 76

What are the clinical insults that constitute SIRS?

Back 76

Tachycardia
Tachypnea
Increased/decreased body temp
increased/decreased WBCs (or left shift w/>10% bands)

Front 77

The presence of viable bacteria in the blood stream describes...

Back 77

...bacteremia

Front 78

What constitutes severe sepsis?

Back 78

Sepsis with at least one organ dysfunction or hypoperfusion.

Front 79

Septic shock occurs when:
a) bacteremia increases beyond 10000 cfu/dL
b) two or more organ systems are impaired
c) at least one organ is impaired
d) sepsis with hypotension unresponsive to fluids

Back 79

d) sepsis with hypotension unresponsive to fluids

Front 80

Which two classes of circulating molecules trigger the pro-inflammatory mediators?

Back 80

DAMPS and PAMPS
Damage-associated and Pathogen associated molecular pattern molecules

Front 81

What are some examples of gram positve toxins?

Back 81

Flagellin
Peptidoglycan
Bacterial DNA

Front 82

How is sepsis diagnosed?

Back 82

Usually 2 or 3 of the following:
Tachycardia
Tachypnea
Pyrexia
WBC changes (leukopenia)

Front 83

How is sepsis treated?

Back 83

Circulatory support
Remove underlying cause
(possibly neutralizing endotoxin)

Front 84

T or F:
Fluids are given in septic cases to alleviate dehydration.

Back 84

False!
It mostly helps with organ perfusion and nutrient distribution.

Front 85

What is the emergency bolus for a 500kg horse?

Back 85

5-10L in 30-60 min

Front 86

Do not use hypertonic saline if > _____ % dehydrated!!!

Back 86

if >8% dehydrated

Front 87

What is probably the most important pharmaceutical when treating sepsis?

Back 87

NSAIDS

Front 88

When are antibiotics indicated in cases of sepsis?

Back 88

Marked immunosuppression
Pneumonia, metritis, etc - DEFINITELY NOT GI ISSUES
Specific diseases (like rickettsial diseases)

Front 89

Name the form of hepatic lipidosis that affects...
...dairy cows.

Back 89

Fat cow syndrome

Front 90

Name the form of hepatic lipidosis that affects...
...beef cows.

Back 90

Protein/energy malnutrition

Front 91

Name the form of hepatic lipidosis that affects...
...ewes and does.

Back 91

Pregnancy toxemia

Front 92

Name the form of hepatic lipidosis that affects...
...ponies and miniature horses.

Back 92

Hyperlipidemia and Hyperlipemia