PT7130: Comprehensive Review of Liver and Gallbladder Anatomy and Functions

Cholesterol; clotting factors; toxins; glucose; ammonia; bile; immune

Functions of Liver:

- Synthesis of fats, proteins (albumin), ________________________

- Produces _________________________

- Metabolizes nutrients from food, _______________________, medications

- Stores ______________________, vitamins, and minerals

- Converts ________________________ to urea

- Makes ______________________ for fat digestion

- ________________________ function

Portal vein

Drains venous blood from the intestine, pancreas, and spleen and transports it to the liver for filtration. → Blood flow could go either way depending on pressure gradient.

Valveless

Portal vein is ________________________.

Portal HTN

Defined as pressure in the portal vein >10 mmHg.

Liver damage

What is major cause of portal HTN?

Varicosing and hemorrhaging

Uncontrolled portal HTN can lead to ___________________________.

- Rectal vein → rectal bleeding

- Esophageal varices → esophageal bleeding

Valsalva maneuver; stool; cough secretions

_________________________ and anything that leads to ↑ intra-abdominal pressure can lead to backflow of blood into esophageal and rectal vv. in presence of portal HTN. → Blood in _______________________ and _______________________.

Fulminant liver failure and hepatocellular carcinoma

What are non-cirrhotic types of liver dysfunction?

Fulminant liver failure

Hepatic insufficiency in the absence of chronic liver disease.

CMV; mononucleosis; acetaminophen; poisonous plant; thrombosis

Causes of Fulminant Liver Failure:

- Acute viral infection: Hepatitis A, B, _______________________, Epstein-Barr virus, ________________________

- Drug overdose: _________________________

- ___________________________

- ___________________________

Pain; appetite; dark; ammonia; liver enzymes

Signs and Symptoms of Fulminant Liver Failure:

- GI symptoms: Abdominal ____________________, N+V, poor _____________________, _____________________ urine

- SIRS

- ↑ _______________________ and ______________________ via lab values

Hepatic encephalopathy

Progression of fulminant liver failure can be rapid and lead to _________________________.

Hepatocellular carcinoma

Non-cirrhotic liver cancer.

Cirrhosis

Chronic and progressive disease where liver cells are damaged, fibrosis development → increases resistance to blood flow.

Alcohol; viral; autoimmune

Causes of Cirrhosis:

- _____________________ (#1 in US)

- ______________________ (Hep B, C)

- _______________________

Asymptomatic

Early in cirrhosis, patient may be _______________________. Chronic alcohol use requires ~10 years.

Jaundice; loss; weakness; ascites; AMS

Signs and Symptoms of Late/Advanced Cirrhosis:

- _____________________

- Weight ____________________

- Malaise

- _____________________

- _____________________

- _____________________ (encephalopathy)

Protein; capillary

Ascites:

Liver failure leads to ↑ _____________________ in interstitium d/t imbalance, ↑ water pulled into interstitium from ______________________.

Alcohol withdrawal syndrome

When cirrhosis is caused by chronic alcoholism, there is risk of development of ___________________________ (delirium tremens "DTs").

GABA; glutamate; hallucinations

Alcohol Withdrawal Syndrome (Delirium Tremens):

- Alcohol is depressant → long-term ________________________ production

- Body compensated by creating ______________________.

- If the individual stops drinking alcohol glutamate > GABA.

- Can lead to ________________________ and AMS.

CIWA scale

Alcohol Withdrawal Syndrome is commonly mild, but if severe, the individual is hospitalized and ______________________ scale is used to monitor and determine level of treatment.

Prolonged; ↑; thrombocytopenia; ↓

Labs /c Cirrhosis:

- ________________________ PT time

- _________________________ INR

- _________________________ d/t splenomegarly secondary to portal HTN

- _________________________ albumin

Sedative effects

Patients /c cirrhosis have ↑ sensitivity to medications, especially those /c ________________________ (i.e., narcotics and benzodiazepines). → Do not metabolize as quickly!

Clotting factors and platelets

Patients /c cirrhosis have a high bleeding risk d/t ↓ ________________________.

Jaundice

What symptom of liver failure does patient in image demonstrate?

Hepatic encephalopathy

Reversible, but common complication of cirrhosis.

Ammonia

Hepatic Encephalopathy:

Liver cannot clear ________________________, excess build up and toxic to brain. Monitor levels.

15-45 u/dL

What is normal value for ammonia?

AMS; sleep cycles; amnesia; ataxia; hyperreflexia

Signs and Symptoms of Hepatic Encephalopathy:

- Confusion

- _________________________

- Altered _______________________

- Poor memory and concentration

- Lethargy

- Fall risk

- ________________________

- ________________________

- Reflexes: _________________________

- ↑ in muscle activity

Coma, seizure, death

Severe cases of hepatic encephalopathy can lead to _______________________.

Esophageal varices

___________________________ is a threatening complication of cirrhosis d/t low platelets.

Asterixis

Wrist flexion/extension tremor /c passive wrist extension while elbow is in extension; also called flapping tremor or liver flap; indicative of hepatic encephalopathy.

Liver enzymes

Used to assess liver function.

Elevated

________________________ levels of liver enzymes are early indicators of liver injury.

Alanine aminotransferase (ALT), aspartate aminotransferase (AST)

What are enzymes present in liver cells?

Model for End Stage Liver Disease (MELD) Score

Score assess risk of death while on liver transplant list.

Shorter; higher

Higher MELD = ______________________ life expectancy = _______________________ on transplant list

Kidney; clotting factor; bilirubin

MELD Score is based on ______________________ function, ______________________ levels, and _________________________ levels.

Once a week

If MELD Score is >25, how often is it re-checked?

Once a year

If MELD Score is <9, how often is it re-checked?

Orthotopic

Diseased liver removed, donor liver replaced.

Living donor

Single lobe of living donor donated, regrowth.

Split liver

1/2 liver to adult, 1/2 liver to child.

Domino liver

Diseased liver (familial amyloidotic polyneuropathy) goes to new recipient, donot liver goes to FAP recipient.

Familial amyloidotic polyneuropathy (FAP)

Metabolic liver defect with fibroids deposited in intestine, heart, nerves, kidney.

40-60 years

FAP liver will still cause fibroids to deposit but will take _______________________ to manifest. → May live a full, health life /c no liver issues till mid-60s when fibroids start to develop.

Glycogen; osteoporosis; ascites; weakness; fatigue

Liver Transplant - Premorbid Condition:

- Deconditioned, malnourished /c loss of muscle d/t breakdown of muscle protein and fat

- ↓ ability to store glucose as _________________________

- Failure to absorb vitamin D → ________________________ → susceptible to fx

- Anasarca and/or ________________________ lead to weight gain → Balance issues d/t new COM location.

- Extreme _______________________ and _______________________

Check prior to PT session; log roll

Liver Transplant - Post-Op Considerations:

- Lots of JP drains! → ___________________________

- Very painful

- Abdominal precautions → ________________________ for bed mobility

Reverse isolation; postural hypotension; ascites; biliary T tube; PNA and atelectasis; abdominal

Liver Transplant - Post-Op Considerations:

- Isolation precautions to reduce risk of infection → _______________________

- Common to need many units of PRBC's, platelets, and plasma during surgery → Hypotensive events, ________________________

- May still have _________________________ and lots of pain d/t abdominal drains and sutures: Increased abdominal girth and LE edema → Balance and COM

- Caution JP drain and ________________________

- Deep breathing exercise → Large risk of ________________________, limited chest expansion d/t pain, ineffective cough

- _______________________ precautions

Log rolling for bed mobility, <20 lbs lifting restriction for 6 weeks

What are abdominal precautions?

Positive; surgical healing; monitoring

Bile production is ______________________ prognostic indicator because it means that new liver is working! → We have to offload it into bile bag for ~3 months post-op d/t _______________________ and _______________________.

Biliary T-tube

What does image show?

Coagulation factors; hyperglycemia; potassium

Liver Transplant - Post-Op Considerations:

- Check _______________________ d/t ↑ risk of bleeding /c prolonged clotting times, should trend back to normal /c return of liver function

- LFT's should trend toward normal

- _______________________ can be a good indicator of return. → Elevations in blood sugar when new liver can convert stored glycogen into glucose.

- Caution and monitor ________________________ trends.

Hypokalemia

Toward __________________ when hepatocytes can extract K+ from the blood.

Hyperkalemia

Toward __________________ is a sign of cell death and nonfunctional hepatocytes.

Tacrolimus (Prograf)

Immunosuppressant, most common anti-rejection medication used after liver transplant.

Tremor; fatigue

Side effects of Tacrolimus (Prograf) include ______________________, paresthesias, and headache, dizziness, and ______________________ (appears similar to stroke).

Prednisone

Corticosteroid used after liver transplant.

Osteoporosis

Long-term use of Prednisone increases risk of ________________________ and fracture.

Fluid retention/edema

Side effect of Prednisone is __________________________.

Changing schedule

If patient is immunocompromised and has low WBC count, talk to team leader about _________________________.

Gallbladder

Stores and concentrates bile.

Bile

Composed of bile salts, cholesterole, bilirubin, lecithin, fatty acids, water, and electrolytes.

Emulsifies fats

What is function of bile?

Cholelithiasis

Gallstones.

Stasis; cholesterol; bilirubin

Causes of Cholelithiasis:

- _____________________ of bile

- ↑ saturation of ______________________ in bile

- ↑ concentration of insoluble ______________________ in bile

US, CT scan, nuclear medicine

Diagnosis of Cholelithiasis:

- Imaging: __________________________

- Can detect stones as small as 1-2 cm

Cholcystitis

Inflammation of the gallbladder - acute or chronic.

Gallstone ductal obstruction

90% of cholecystitis cases are related to _________________________.

Right upper quadrant; gallbladder attacks; rigidity; jaundice; fever

Signs and Symptoms of Cholecystitis:

- Abdominal pain in ______________________, severe /c abrupt onset and steadily increasing over 2-8 hours → soreness

- ________________________ usually subside s/p 7-10 days

- Rebound tenderness, abdominal _________________________

- _________________________

- N+V

- _________________________

Murphy's sign

Pain /c inhalation when fingers hooked under R ribs; indicative of cholecystitis.

NG; pain; IV

Treatment of Cholecystitis:

- Bowel rest → _______________________ suctioning

- ERCP

- Laparoscopic cholecystectomy

- Cholecystostomy

- ________________________ management

- ______________________ fluids

- Antibiotics

Endoscopic retrograde cholangiopancreatography (ERCP)

Remove stones blocking bile ducts or cystic duct.

Laparoscopic cholecystectomy

Remove gallbladder.

Cholecystostomy

Gallbladder drainage catheter placement.

McBurney's point

Pain upon palpation of R LQ point (1/2 of the way from the ASIS to the umbilicus); indicative of appendicitis.

Rovsing's sign

Pain in R LQ /c application of pressure to L LQ; indicative of appendicitis.