Liver & Bleeding

What are the five functions of liver

carb metabolism

protein synthesis

lipid metabolism

bilirubin conjugation

drug metabolism

Low serum glucose = _____

high serum glucose = ______

low = glycogenolysis, gluconeogenesis

high = glycogen synthesis

T/F: liver synthesizes albumin, clotting facotr, angiotensinogen

True

Liver manufactures ___% of cholesterol

80%

What is hepatitis caused by?

virus

What are the most common forms of hepititis?

HAV

HBV

HCV

(remember: ABC)

T/F: liver problems can range from asymptomatic to life threatening

true

Which type of hepatitis does NOT have a vaccine?

C

Which type of hepatitis can develop chronically?

B & C

Which types of hepatitis is DNA based?

B (A & C are RNA based)

What are the three phases of acute viral hepatitis?

1. pre-icteric: malaise, anorexia & loss of taste, cough

2. icteric: 1-4 weeks, UR quad pain, pruritus (itch), weight loss, jaundice (bilirubin >2.5)

   1. convalescent: all constitutional symptoms resolved, resolution in 3-6 months

How is hep A spread?

fecal-oral route contaminated food

How is hep B spread?

infected blood, sexual contact

Chronic hepatitis B incidence is ____%

1-2%

___% of chronic hepatitis B develops into cirrhosis

40%

How is hep c spread?

parenteral (injection)

What is the incidence of chronic hep c?

85%

How many chronic hep c cases develop cirrhosis?

30%

T/F: alcohol associated liver disease is reversible and may develop ETOH cirrhosis ___%

true

10-15%

What is associated with nonalcoholic fatty liver disease

obesity & metabolic syndrome

What is steatosis

fat infiltration in liver

What does NASH stand for

nonalcoholic steatohepatitis

What is NASH

progressive form of fatty liver

T/F: NASH is reversible

false, NASH IS IRREVERSIBLE

T/F: NASH will always develop cirrhosis

True

What is cirrhosis

irreversible damage to liver

T/F: all patients with cirrhosis develop life threatening injuries

False

What is the primary cause of cirrhosis

alcohol (other causes: HCV & NASH)

What are the three stages of cirrhosis

1. compensated

2. compensated with varices

3. decompensated

Cirrhosis is known for sweet breath odor called

fetor hepatitis

Pts with cirrhosis have lab results high in ___

GGT (also elevated with obesity/alcohol/acetaminophen)

What is this? What is it a sign of?

digit clubbing & terry nails

cirrhosis

What is this? What is it a sign of?

spider angiomas

cirrhosis

What is this? What is it a sign of?

dupuytren’s contracture

cirrhosis

T/F: portal vein has no valves

true

What is the condition called that transitions from compensated to decompensated cirrhosis

portal HTN

What are three things characteristic about portal HTN

ascites

esophageal & gastric varices

splenomegaly

What are ascites

fluid in peritoneal cavity

T/F: you need portal HTN in order for ascies to form

true

__% of cirrhosis pts develop gastroesophageal varices with a gradient of __ mm

50%

>12mm

What is this? What is it associated with?

asterixis

hepatic encephalopathy

Loss of clotting factors is associated with ___

cirrhosis

Vitamin K is necessary for factors ___ ___ ___ and __

II

VII

IX

X

Inability for liver to remove activated factors and fibrin products leads to __

DIC

What is at highest risk for hepatocellular carcinoma?

chronic HBV

What are the four factors of child-pugh (PAUSE) cirrhosis classification

degree of ascites

albumin & bilirubin levels

INR

encephalopathy degree

Child-Pugh Class A and C score and impression

A: 5-6, well compensated

C: 10-15, decompensated

What is the MELD score for Child-Pugh A

<10

What is the perioperative mortality rate of CTP A, B, C?

A:10%

B: 20%

C: 50%

T/F: cirrhosis viewed as hypo coaguloppathy

True

T/F: pt with liver dx you correlate risk of bleeding with lab results

FALSE

What is the risk of major bleed in low bleed procedure vs high bleed procedure?

low:<1.5%

high:>1.5%

T/F: dentoalveolar surgery is low bleed risk

true

What was risk of bleed for dentoalveolar surgery

2.6-6%

What analgesic used for chronic liver dx

acetaminophen

What is the max dosage a day for acetaminophen for liver dx

2g/day

What is the toxic metabolite of acetominophen

NAPQI

NSAIDs increase the risk of: (3)

hemorrhage

impaired renal function

diuretic resistant ascites

T/F: you want to avoid NSAIDs in advance liver dx/cirrhosis

true

What medication is the best PO choice for severe liver dx

hydromorphone

Which med is “good parenteral opioid

fentanyl

What is the best anesthetic opioid? What is it metabolized by?

remifentanil

plasma esterases

What is the most common inherited bleeding disorder

von willebrand dx

What is the minimal platelet level for local anesthesia, blocks, extractions

50,000 to 80,000

T/F: hemophilia a is an x linked recessive, therefore males have it and females carry

true

What do PT - INR tests for

measures deficiencies in extrinsic pathway & common pathway

What does aPTT measure

measures deficiencies in intrinsic pathway & common pathway

What are causes of thrombocytopenia

anemia, folate deficiency, chemo, hereditary, HIV, cirrhosis, DIC, hypersplennism

What is von willebrand dx

disorder of platelet aggregation & adhesion

What is the difference between von willebrand dx type 1, 2a, 3

Type 1: quaNTitative vWF deficiency, 70-80% cases

Type 2A: quaLitative vWF deficiency

Type 3: rare disorder

What does von willebrand factor antigen level (VWF: Ag) measure

amount of vWF in blood

What is the gold standard for measuring factor activity

RCo

What are the lab tests results for type 1,2,3 vW dx

Normal: RCo (50-166), Ag (50-249) VIII (50-186)

Type 1: RCo (<50), Ag (<50), VIII (normal)

Type 2A: RCo (decrease), Ag (normal), VIII (normal)

Type 3: RCo (<3), Ag (<3), VIII (<10)

T/F: DDAVP for Type 1 restrict post op fluid to prevent hyponatremia

true

T/F: desmopressin only effective for type 3

false; only effective for type 1

What should you do for type 2 and 3

contact hematologist

Severe states of hemophilia a comprise __% of all cases

60%

What level of factor VII is needed to constitute severe hempphilia

<1%

Lab results for hemophilia (PTT, P, platelet)

prolonged PTT

normal PT

normal platelet count

Clotting test times for aPTT and PT

aPTT: 25-39 sec

PT: 12 sec

What are the two meds used for mild hemophilia surgical pts

DDAVP

epsilon aminocaproic acid

T/F: both hemophilia A and B are both x linked

True

Which is more popular hemophilia A or B

A

T/F: pts with factor inhibitors require higher replalcement with recombiant product

true