Podcast
Questions and Answers
What is the primary function of bile in the body? Select 3
What is the primary function of bile in the body? Select 3
Which vitamin is necessary for the synthesis of clotting factors II, VII, IX, and X?
Which vitamin is necessary for the synthesis of clotting factors II, VII, IX, and X?
Which zone of the liver acinus is most susceptible to ischemic injury due to its distance from the hepatic artery?
Which zone of the liver acinus is most susceptible to ischemic injury due to its distance from the hepatic artery?
What is the major end-product of hemoglobin degradation?
What is the major end-product of hemoglobin degradation?
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Which factor has the shortest half-life among the clotting factors synthesized by the liver?
Which factor has the shortest half-life among the clotting factors synthesized by the liver?
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How does excess iron get stored in the liver?
How does excess iron get stored in the liver?
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Kupffer cells primarily function in which way within the liver?
Kupffer cells primarily function in which way within the liver?
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Where does bile flow after exiting the liver lobules?
Where does bile flow after exiting the liver lobules?
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What is the primary reason for increased cardiac output in cirrhotic patients?
What is the primary reason for increased cardiac output in cirrhotic patients?
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How does Hepatorenal Syndrome (prerenal disease) primarily manifest? Select 3
How does Hepatorenal Syndrome (prerenal disease) primarily manifest? Select 3
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What defines severe portal hypertension in terms of hepatic venous pressure gradient (HVPG)?
What defines severe portal hypertension in terms of hepatic venous pressure gradient (HVPG)?
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What is a characteristic feature of cirrhotic cardiomyopathy? Select all that apply
What is a characteristic feature of cirrhotic cardiomyopathy? Select all that apply
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What is the primary treatment for varices resulting from portal hypertension? (select 2)
What is the primary treatment for varices resulting from portal hypertension? (select 2)
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What impact does chronic cholestatic disease have on hepatocytes?
What impact does chronic cholestatic disease have on hepatocytes?
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Why is it important to slowly correct hyponatremia in patients with hepatic encephalopathy?
Why is it important to slowly correct hyponatremia in patients with hepatic encephalopathy?
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What is the primary function of the Sphincter of Oddi?
What is the primary function of the Sphincter of Oddi?
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Which of the following tests primarily reflects hepatic synthetic function? Select all that apply
Which of the following tests primarily reflects hepatic synthetic function? Select all that apply
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What indicates a potential alcoholic liver disease when evaluating AST and ALT levels?
What indicates a potential alcoholic liver disease when evaluating AST and ALT levels?
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Which enzyme is considered the most specific marker of liver injury?
Which enzyme is considered the most specific marker of liver injury?
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What condition is most commonly associated with extreme elevations of LDH? select 2
What condition is most commonly associated with extreme elevations of LDH? select 2
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Which of the following statements about alkaline phosphatase is correct? select 2
Which of the following statements about alkaline phosphatase is correct? select 2
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What does an elevation in serum bilirubin levels primarily indicate?
What does an elevation in serum bilirubin levels primarily indicate?
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Which of the following is true regarding the performance of liver function tests (LFTs)?
Which of the following is true regarding the performance of liver function tests (LFTs)?
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What causes the hepatic artery buffer response (HABR) to occur?
What causes the hepatic artery buffer response (HABR) to occur?
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Which component makes up 80% of the liver mass and is responsible for various metabolic processes?
Which component makes up 80% of the liver mass and is responsible for various metabolic processes?
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What is the average pressure in the portal vein?
What is the average pressure in the portal vein?
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Which type of liver cell is primarily involved in regulating hepatic vascular tone and permeability in the lobule?
Which type of liver cell is primarily involved in regulating hepatic vascular tone and permeability in the lobule?
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What effect does sympathetic nervous system stimulation have on hepatic blood flow?
What effect does sympathetic nervous system stimulation have on hepatic blood flow?
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Which process involves converting lactate, glycerol, and amino acids into glucose in the liver?
Which process involves converting lactate, glycerol, and amino acids into glucose in the liver?
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How does the liver contribute to tolerating hemodynamic changes during hemorrhage?
How does the liver contribute to tolerating hemodynamic changes during hemorrhage?
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What is the most common cause of elevated liver enzymes in adults?
What is the most common cause of elevated liver enzymes in adults?
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Which treatment is recommended for Nonalcoholic Fatty Liver Disease (NAFLD)?
Which treatment is recommended for Nonalcoholic Fatty Liver Disease (NAFLD)?
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What should be indicated by elevated alkaline phosphatase and elevated transaminases in a patient?
What should be indicated by elevated alkaline phosphatase and elevated transaminases in a patient?
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Which of the following complications may lead to increased Vd of drugs in patients with liver disease?
Which of the following complications may lead to increased Vd of drugs in patients with liver disease?
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What is a consideration regarding the use of midazolam in patients with liver disease?
What is a consideration regarding the use of midazolam in patients with liver disease?
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Which of the following can increase the risk of aspiration and rapid desaturation during general anesthesia induction?
Which of the following can increase the risk of aspiration and rapid desaturation during general anesthesia induction?
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Which anesthetic agent is often considered the best choice due to its short duration in patients with liver disease?
Which anesthetic agent is often considered the best choice due to its short duration in patients with liver disease?
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Which of the following is NOT a function of hepatocytes?
Which of the following is NOT a function of hepatocytes?
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What is the major end-product of hemoglobin degradation that is excreted by the liver?
What is the major end-product of hemoglobin degradation that is excreted by the liver?
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What structure divides the left and right lobes of the liver?
What structure divides the left and right lobes of the liver?
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Which component of the liver is responsible for storing Vitamin A and the regulation of sinusoidal circulation?
Which component of the liver is responsible for storing Vitamin A and the regulation of sinusoidal circulation?
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Which of the following is NOT part of the liver's synthetic function? select 2
Which of the following is NOT part of the liver's synthetic function? select 2
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The hepatic artery buffer response (HABR) compensates for decreased portal vein blood flow through which mediator?
The hepatic artery buffer response (HABR) compensates for decreased portal vein blood flow through which mediator?
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What is the primary cause of portal hypertension in cirrhosis?
What is the primary cause of portal hypertension in cirrhosis?
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In the context of anesthetic implications for liver disease, which approach is recommended to reduce the risk of CNS depression?
In the context of anesthetic implications for liver disease, which approach is recommended to reduce the risk of CNS depression?
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Which of the following is a characteristic of hepatopulmonary syndrome?
Which of the following is a characteristic of hepatopulmonary syndrome?
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The presence of spider angiomas in a patient with liver disease is often associated with which complication?
The presence of spider angiomas in a patient with liver disease is often associated with which complication?
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Which type of hepatitis is most likely to develop into a chronic infection?
Which type of hepatitis is most likely to develop into a chronic infection?
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How does the liver handle ammonia produced as a byproduct of protein metabolism?
How does the liver handle ammonia produced as a byproduct of protein metabolism?
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What role does albumin play in maintaining blood chemistry and volume?
What role does albumin play in maintaining blood chemistry and volume?
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Which vessel supplies the majority of blood flow (75%) and 50% of the oxygen to the liver?
Which vessel supplies the majority of blood flow (75%) and 50% of the oxygen to the liver?
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Which vessel carries nutrient-rich, oxygen poor blood from the gastrointestinal tract to the liver?
Which vessel carries nutrient-rich, oxygen poor blood from the gastrointestinal tract to the liver?
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Which vessel has the lowest pressure in the major hepatic vessels and drains blood from the liver to the inferior vena cava?
Which vessel has the lowest pressure in the major hepatic vessels and drains blood from the liver to the inferior vena cava?
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What is the approximate average pressure in the hepatic artery?
What is the approximate average pressure in the hepatic artery?
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The hepatic artery arises from which major vessel?
The hepatic artery arises from which major vessel?
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Which vessel supplies 25% of the flow but 50% of the oxygenated blood to the liver?
Which vessel supplies 25% of the flow but 50% of the oxygenated blood to the liver?
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What percentage of cardiac output does the liver receive?
What percentage of cardiac output does the liver receive?
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What factors determine hepatic blood flow?
What factors determine hepatic blood flow?
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Which of the following factors decrease hepatic blood flow? (Select all that apply)
Which of the following factors decrease hepatic blood flow? (Select all that apply)
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How does SNS stimulation result in decreased hepatic blood flow?
How does SNS stimulation result in decreased hepatic blood flow?
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What can impede the hepatic artery buffer response (HABR)? select 2
What can impede the hepatic artery buffer response (HABR)? select 2
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Match the description with its appropriate definition:
Match the description with its appropriate definition:
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Ammonia level does not correlate with severity of encephalopathy due to its high potency/toxicity.
Ammonia level does not correlate with severity of encephalopathy due to its high potency/toxicity.
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What is the predominant plasma protein in human blood?
What is the predominant plasma protein in human blood?
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If a patient has signs of liver dysfunction with a normal albumin level, what type of problem is this indicative of?
If a patient has signs of liver dysfunction with a normal albumin level, what type of problem is this indicative of?
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What are the key functions of the liver? (Select all that apply)
What are the key functions of the liver? (Select all that apply)
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Which of the following plasma proteins are produced by the liver? (Select all that apply)
Which of the following plasma proteins are produced by the liver? (Select all that apply)
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What are Phase 1 reactions in drug metabolism?
What are Phase 1 reactions in drug metabolism?
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What type of reactions involve cytochrome P450 enzymes?
What type of reactions involve cytochrome P450 enzymes?
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What is the purpose of the phase 2 conjugation reactions?
What is the purpose of the phase 2 conjugation reactions?
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What is the first pass effect?
What is the first pass effect?
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What is a characteristic of a high hepatic clearance drug?
What is a characteristic of a high hepatic clearance drug?
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Which type of drug clearance is independent of hepatic blood flow?
Which type of drug clearance is independent of hepatic blood flow?
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What percentage of the body's lymph does the liver generate?
What percentage of the body's lymph does the liver generate?
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Which of the following hormones does the liver synthesize? (Select one)
Which of the following hormones does the liver synthesize? (Select one)
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What type of cell produces bile in the liver?
What type of cell produces bile in the liver?
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Match the steps in the pathway for bile production and excretion:
Match the steps in the pathway for bile production and excretion:
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Match the steps of hemoglobin (Hgb) catabolism:
Match the steps of hemoglobin (Hgb) catabolism:
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DAKE = fat-soluble vitamins
DAKE = fat-soluble vitamins
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Which of the following nutrients are stored in the liver? (Select all that apply)
Which of the following nutrients are stored in the liver? (Select all that apply)
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What organ is the site for the clearance of activated clotting factors?
What organ is the site for the clearance of activated clotting factors?
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Which clotting factor is elevated in the setting of liver disease as a compensatory mechanism?
Which clotting factor is elevated in the setting of liver disease as a compensatory mechanism?
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What is the anatomical and functional unit of the liver called?
What is the anatomical and functional unit of the liver called?
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What does each liver lobule consist of?
What does each liver lobule consist of?
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What are the components of the portal triad?
What are the components of the portal triad?
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What is the acinus?
What is the acinus?
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What activities occur in zone 3 of the liver? (Select all that apply)
What activities occur in zone 3 of the liver? (Select all that apply)
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What is the Ampulla of Vater?
What is the Ampulla of Vater?
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Why do abnormal liver function tests (LFTs) occur late in liver disease?
Why do abnormal liver function tests (LFTs) occur late in liver disease?
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Which of the following tests are used to assess hepatic excretory function and clearance?
Which of the following tests are used to assess hepatic excretory function and clearance?
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Which test can be used to assess cholestatic or obstructive conditions?
Which test can be used to assess cholestatic or obstructive conditions?
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Which of the following tests can be used to assess hepatic cellular integrity?
Which of the following tests can be used to assess hepatic cellular integrity?
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What test is commonly used to assess hepatic detoxification function?
What test is commonly used to assess hepatic detoxification function?
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Which of the following statements about aminotransferases is correct?
Which of the following statements about aminotransferases is correct?
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Which tissues can AST (aspartate aminotransferase) be found in?
Which tissues can AST (aspartate aminotransferase) be found in?
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Which of the following are non-specific markers of hepatocellular injury due to their location in extrahepatic tissues? (Select all that apply)
Which of the following are non-specific markers of hepatocellular injury due to their location in extrahepatic tissues? (Select all that apply)
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What is the most common cause of acute liver failure?
What is the most common cause of acute liver failure?
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What are non-hepatic causes of increased bilirubin? (Select all that apply)
What are non-hepatic causes of increased bilirubin? (Select all that apply)
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An increase in which lab values indicate obstructive liver or cholestatic disease? select 2
An increase in which lab values indicate obstructive liver or cholestatic disease? select 2
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What does prothrombin time measure?
What does prothrombin time measure?
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What liver function test is noted for its sensitivity to liver injury due to its short half-life?
What liver function test is noted for its sensitivity to liver injury due to its short half-life?
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In cirrhosis, which of the following mechanisms primarily contributes to the condition being a low systemic vascular resistance (SVR) state?
In cirrhosis, which of the following mechanisms primarily contributes to the condition being a low systemic vascular resistance (SVR) state?
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Stored in liver = I BAKED
iron
Vit B12, A, K, E, D
Stored in liver = I BAKED iron Vit B12, A, K, E, D
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Study Notes
Liver Gross Anatomy
- Divided into 4 lobes: left, right, quadrate, caudate
- Left and right lobes are divided by the falciform ligament
- Liver is the second largest organ in the body, the skin is first
- Enclosed within Glisson's capsule
Couinard Classification
- Division of the liver into 8 independent functional units
- Used for surgical classification
- Each unit has its own vascular supply
Hepatic Blood Flow
- Receives 25% of cardiac output from the hepatic artery and portal vein
Hepatic Artery
- Supplies less of the total blood supply to the liver (20%) than the portal vein, but better oxygenated blood
- Average pressure is 90 mmHg
- Comes off of the celiac artery
Portal Vein
- Blood draining from the gastrointestinal tract that is rich in nutrients and bacteria
- Average pressure is 8-10 mmHg
- Supplies most of the blood to the liver (75%), but less oxygenated
Hepatic Vein
- Pressure is 4 mmHg
- Not a steep gradient between portal vein and hepatic vein
- Total hepatic blood flow = portal vein + hepatic artery
- Hepatic artery supplies about 50% of total O2 and portal vein has 50% of total O2 to the liver
Hepatic Blood Flow Determination
- 800 to 1200 ml of blood flow per minute
- Hepatic blood flow is determined by hepatic perfusion pressure (HPP) and splanchnic vascular resistance
- HPP = hepatic perfusion pressure = mean arterial pressure minus hepatic vein pressure or portal vein pressure minus hepatic vein pressure
- Splanchnic vessels are innervated by the sympathetic nervous system
- Sympathetic nervous system stimulation increases splanchnic vascular resistance resulting in decreased hepatic blood flow
- Hepatic blood flow is reduced by pain, hypoxia, catecholamines, volatile anesthetics, regional anesthesia, surgical site, positive pressure ventilation, excess fluid administration
Hepatic Artery Buffer Response (HABR)
- Hepatic artery tone adjusts to changes in portal blood flow up to a 100% increase
- Response is mediated by adenosine
- Decreased portal vein blood flow leads to low pH, low O2, or hypercapnia → increased adenosine → hepatic artery vasodilates
- Portal vein does not compensate for changes in hepatic artery supply
- Volatile anesthetics and cirrhosis interfere with this response
Hepatocyte
- Make up 80% of liver mass
- Store glycogen, vitamin B12, and iron
- Participate in lipid turnover and transport
- Synthesize plasma proteins (albumin, prothrombin, fibrinogen)
- Metabolize and detoxify fat
- Turnover of steroid hormones
- Regulate cholesterol
- Secrete bile
Myeloid Cells
- Kupffer cells play a critical role in detoxification and act as phagocytic macrophages
- Located in portal and lobular liver sinusoids
- Dendritic cells promote tolerance to phagocytized particles
- Hepatic myeloid-derived suppressor cells suppress the immune response in the liver
Hepatic Stellate Cells
- Reside in the space of Disse
- Store vitamin A and regulate sinusoidal circulation
- Can proliferate in liver injury leading to hepatic inflammation and fibrosis
Liver Sinusoidal Endothelial Cells
- Permeable barrier that helps regulate hepatic vascular tone
- Separates blood cells from hepatocytes/hepatic stellate cells
Functions of the Liver
- Filtration and storage of blood
- Moderates hypotensive response to hemorrhage and hypovolemia
- Liver is expandable and can store up to 1 L of blood – liver has ability to autotransfuse blood
- Forms about 50% of body's lymph
Metabolism of Carbohydrates
- Glycogenesis = converting glucose to glycogen
- Glycogenolysis = breakdown of glycogen for glucose
- Lipogenesis = converting excess glucose into fat
- Gluconeogenesis = converting lactate, glycerol, and amino acids to glucose; also converting galactose and fructose to glucose = creating glucose from non-carbohydrate sources
Protein Metabolism in the Liver
- Deamination of amino acids/proteins to form carbs or fat. Ammonia is a byproduct of this reaction.
Elimination of Foreign And Chemical Toxins
- Kupffer cells act as macrophages and filter so that <1% of bacteria from gut gets through the circulation.
- Liver also generates 50% of body's lymph.
Hgb Breakdown
- Bilirubin is the major end-product of hemoglobin degradation that gets excreted by the liver
- Heme gets converted to bilirubin
- Bilirubin excreted into bile duct
Formation of Bile
- Bile is produced by hepatocytes.
- Bile facilitates excretion of toxins and absorption of dietary fats.
- Bile used to excrete endogenous compounds and exogenous compounds.
- Bile flows from liver lobules → common bile duct → duodenum through the ampulla of Vater.
Storage of Vitamins And Iron
- Fat soluble vitamins = A, D, E, and K
- Vitamin A (10-month supply)
- Vitamin B12 (> 1 year supply)
- Vitamin D (3-month supply)
- Vitamin K necessary for synthesis of Factors II, VII, IX and X
- Iron
- Excess iron binds with apoferritin and is stored in the liver as ferritin.
Formation of Clotting Factors
- Except factors III, IV, and VIII that are all produced outside of the liver.
- Hepatocytes contain apoferritin (which combines reversibly with iron)
- Liver is the site for synthesis of all procoagulant and anticoagulant factors
- Factor VIII elevated in the setting of liver disease
- Liver is also the site for clearance of activated factors
- Factor 7 has the shortest half-life
- Evaluate factor 7 via PT blood test
Each Liver Lobule is an Anatomic and Functional Unit of the Liver
- Consists of a portal triad, plate of hepatocytes, and a central vein
- Portal triad = branch of hepatic artery, branch of portal vein, and bile ducts
- Acinus = functional unit of the liver
- Zone 1 - Periportal
- Well-oxygenated hepatocytes
- Very nutrient-rich
- Responsible for oxidative activities
- Zone 2 - Midzone
- Zone 3
- Hepatocytes furthest from blood supply
- Penetrating vessels
- Most susceptible to ischemic injury because they are the furthest from blood supply
- Responsible for glycolysis, lipogenesis, detoxification, and biotransformation of drugs occur
- Zone 1 - Periportal
Bile Synthesis, Function and Drainage
- Facilitates excretion of toxins & absorption of dietary fats.
- Also used to excrete endogenous compounds (bile acids, bilirubin, phospholipids, cholesterol, steroid hormones) and exogenous compounds (drugs, toxins)
- Bile flows from liver lobules → common bile duct → sphincter of Oddi → ampulla of Vater to the duodenum.
- Sphincter of Oddi is a muscular valve that controls flow of bile and pancreatic juices into the small intestine via the ampulla of Vater.
Blood Flow in/around Liver Lobules
- Space of Disse lies between sinusoidal capillaries and hepatocytes.
Liver Function Tests
- Do not measure specific liver function.
- Abnormalities are late in hepatic disease due to the segmental nature of the liver that provides redundancy.
- Reflect hepatocellular injury, more than liver function.
- LFTs can help define pathophysiology with clinical assessment.
- Hepatic synthetic function:
- Serum albumin, PT, INR, serum cholesterol, plasma pseudocholinesterase
- Hepatic protein synthesis: serum albumin, prothrombin time, INR
- Hepatic excretory function/clearance: direct bilirubin
- Cholestatic or infiltrative conditions: alkaline phosphatase
- Hepatic cellular integrity: AST, ALT, LDH, GST
- Hepatic detoxification function: ammonia
Aminotransferases
- ALT primarily found in the liver and the most specific marker of liver injury.
- AST found in the liver and non-hepatic tissue
- ALT and AST can be normal in end-stage liver disease because there are no cells left to be injured.
- Mild elevations occur with any hepatocyte injury.
- Large elevations are indicative of hepatic necrosis, fulminant viral hepatitis, drug-induced liver injury, shock liver.
- Ratio of AST/ALT = 2 indicates alcoholic liver disease
LDH = Lactate Dehydrogenase
- Non-specific marker of hepatic injury.
- Extreme elevations seen with ischemia or drug-induced hepatotoxicity (e.g.Tylenol OD)
- Tylenol OD is the most common cause of acute liver failure.
- Extrahepatic disorders can increase LDH (e.g.hemolysis, rhabdo, tumor necrosis, renal infarction, MI)
GST = Gluthathione-S-Transferase
- Sensitive for liver injury and short half life.
Alkaline Phosphatase (AP):
- Mild elevations may be normal
- Non-specific (found in extra-hepatic tissues)
- Values 2-4x normal seen in cholestatic disease
- Can indicate intrahepatic or extrahepatic biliary obstruction
Serum Bilirubin
- Indicates excretory function of the liver.
Portal HTN
- Increased resistance to blood flow thru the liver leads to portal hypertension (+5 mmHg)
- Considered severe if hepatic venous pressure gradient (HVPG) >10-12 mm Hg
Hemostasis
- Disrupted balance between bleeding and clotting
Cirrhotic Cardiomyopathy
- Hyperdynamic circulation characterized by high cardiac output, low blood pressure, and low systemic vascular resistance.
- Increased overall fluid volume with decreased circulating volume
- Prolonged QT
Hepatorenal Syndrome (HRS)
- Prerenal disease characterized by sodium and water retention
- Increased prostaglandin levels to help maintain renal perfusion
- Increased sensitivity to nephrotoxic drugs e.g.aminoglycosides, ACEIs, ARBs
Hepatopulmonary Syndrome
- Triad of liver dysfunction, unexplained hypoxemia, intrapulmonary vascular dilation
Postpulmonary HTN
- Pulmonary HTN in a Patient With Portal HTN
Hepatic Hydrothorax
- Ascites fluid passes from peritoneal cavity to the pleural space
Hepatic Encephalopathy
- Result of accumulated neurotoxins directly affecting the brain (e.g.ammonia and others)
- Symptoms = altered mental status, hyper-reflexiveness, nystagmus, decerebrate posturing.
- Mortality is related to infection.
- Treatment = paracentesis and slow correction of hyponatremia.
Varices
- End result of portal HTN
- Treat with beta-blockers to decrease portal pressure and endoscopic ligation.
Chronic Cholestatic Disease
- Impaired bile flow increases biliary pressure and backflow into the liver resulting in hepatocyte destruction.
- If bacteria in bile -> ascending cholangitis, hepatic abscess, sepsis, and acute kidney injury can occur
- Deficiencies in Vitamin K-dependent clotting factors (II, VII, IX, X)
- Hypercoagulability
- Extrahepatic causes = obstruction
- Labs = Elevated serum AP and GT; may have elevated bilirubin
- Treatment = endoscopic retrograde pancreatography (ERCP)
Hepatocellular Carcinoma
- Most common primary liver malignancy and 3rd most common cause of death globally.
- Treatment = surgical resection, liver transplant, ablation, chemoembolization
Nonalcoholic Fatty Liver Disease (NAFLD)
- Ranges in severity from steatosis (fat deposits on the liver) to hepatocellular necrosis (NASH/steatohepatitis)
- Associated with metabolic syndrome
- Most common cause of elevated liver enzymes in adults
- Treatment = weight loss or bariatric surgery
Anesthetic Implications
- Signs to look for during preop assessment = jaundice, bleeding abnormalities, spider angiomas
- Spider angiomas are associated with varices and hepatopulmonary syndrome.
- Avoid routine screening LFTs. Test if indicated by physical exam/history.
- Preop LFTs:
- Elevated ALT and AST in asymptomatic patient? Proceed if <2x normal and normal alk phos, bilirubin, INR.
- Transaminases > 2x normal □ Workup prior to elective surgery (US, CT, liver biopsy).
- Both transaminases and INR abnormal □ Workup prior to elective surgery (US, CT, liver biopsy).
- Elevated alk phos and elevated transaminases □ Suspect biliary disease and workup indicated.
Altered Pharmacokinetics
- Altered protein binding – low albumin so reduced protein to bind resulting in more free drug.
- Altered Volume of distribution with ascites and increased total body weight.
- Reduced metabolism.
- Potentiation of anticoagulants due to decreased production of clotting factors.
- Smaller doses of meds at longer intervals.
Induction of GA
- Increased aspiration risk, rapid desaturation and hypoxemia.
- Increased susceptibility to CNS depressants.
Precedex
- Liver metabolism primarily.
- Decreased clearance and prolonged half-life
Midazolam
- Reduced clearance prolongs elimination half-life.
- Avoid precedex and midazolam/any drugs that are primarily cleared hepatically.
Goal platelet >50k
- Opioids - fentanyl is best choice due to its short duration, remifentanil can be used as well but caution for hyperalgesia.
- All volatiles decrease cardiac output which can ultimately decrease hepatic blood flow.
Hepatocyte Functions
- Hepatocytes are responsible for various functions, including synthesis of plasma proteins, storage of Vitamin B12, and secretion of bile.
- They are NOT responsible for blood filtration, which is primarily performed by the kidneys.
Hemoglobin Breakdown
- Bilirubin is the major end-product of hemoglobin degradation excreted by the liver.
Prolonged Prothrombin Time (PT)
- A prolonged PT indicates a dysfunction in protein synthesis within the liver.
Liver Anatomy
- The Falciform ligament divides the left and right lobes of the liver.
Vitamin A Storage
- Hepatic stellate cells are responsible for storing Vitamin A within the liver.
Liver Synthetic Functions
- The liver synthesizes clotting factors II, VII, IX, and X, as well as plasma proteins like albumin.
- Gamma globulin synthesis is NOT a function of the liver; B lymphocytes are responsible for this.
Hepatic Artery Buffer Response (HABR)
- HABR compensates for decreased portal vein blood flow by releasing adenosine.
Liver Excretory Function Assessment
- Direct (conjugated) bilirubin is used to assess liver excretory function.
Portal Hypertension in Cirrhosis
- Increased resistance to blood flow due to fibrosis is the primary cause of portal hypertension in cirrhosis.
Anesthetic Implications for Liver Disease
- Reducing the doses of CNS depressants and lengthening intervals between doses is recommended for patients with liver disease to minimize the risk of CNS depression.
Hepatopulmonary Syndrome
- Hepatopulmonary syndrome is characterized by a triad of liver dysfunction, unexplained hypoxemia, and pulmonary hypertension.
- It is not limited to acute liver disease and can occur in patients with chronic liver disease as well.
Spider Angiomas and Liver Disease
- Spider angiomas are often associated with portal hypertension and varices in patients with liver disease.
Chronic Hepatitis Infections
- Hepatitis C (Type C) is the most likely type of hepatitis to develop into a chronic infection.
Elevated Prothrombin Time and INR in Liver Disease
- An elevated prothrombin time and prolonged INR in patients with liver disease indicate poor protein synthesis and clotting factor production.
Ammonia Metabolism in the Liver
- The liver converts ammonia to urea for excretion.
Albumin's Role in Blood Chemistry and Volume
- Albumin plays a significant role in maintaining intravascular fluid volume and binding to various medications.
Liver Blood Flow Vessels
-
Portal Vein
- Supplies the majority of blood flow to the liver.
- Carries nutrient-rich blood from the gastrointestinal tract.
- Blood is less oxygenated.
-
Hepatic Artery
- Provides oxygen-rich blood to the liver.
- Arises from the aorta via the celiac artery.
-
Hepatic Vein
- Drains blood from the liver and delivers it to the inferior vena cava.
- Has the lowest blood pressure amongst these vessels.
Blood Flow Percentages
- The hepatic artery contributes about 50% of the liver's oxygen supply.
- The portal vein carries about 75% of the total blood flow to the liver.
Hepatic Artery Pressure
- The approximate average pressure in the hepatic artery is 90 mmHg.
Bile's Role
- Primary function: Emulsifies fats in the small intestine, aiding digestion and absorption
Vitamin K Synthesis
- Necessary for: Clotting factors II, VII, IX, and X synthesis
Liver Acinus Zones
- Zone 3: Most susceptible to ischemic injury due to distance from hepatic artery
Hemoglobin Degradation
- Major end-product: Bilirubin
Clotting Factor Half-Life
- Shortest half-life: Factor VII
Liver Iron Storage
- Excess iron: Stored as ferritin
Kupffer Cells
- Primary function: Phagocytosis within the liver
Bile Flow
- Exits liver lobules: Enters bile ducts
Cardiac Output in Cirrhosis
- Increased due to: Hyperdynamic circulation, splanchnic vasodilation & reduced systemic vascular resistance
Hepatorenal Syndrome (prerenal disease) Manifestations
- Low urine output: Due to decreased glomerular filtration rate
- Increased BUN: Reflects impaired renal function
- Elevates creatinine: Indicates kidney failure
Severe Portal Hypertension
- Defined by HVPG: Greater than or equal to 12 mmHg
Cirrhotic Cardiomyopathy Features
- Dilated cardiomyopathy: Weakens heart muscle
- Diastolic dysfunction: Impairs heart's ability to relax and fill
- Reduced contractility: Weakens the heart's pumping power
Portal Hypertension Varices Treatment
- Endoscopic variceal ligation: Banding to stop bleeding
- Beta-blockers: Reduce portal pressure
Chronic Cholestatic Disease Impact
- Hepatocyte damage: Due to bile accumulation and injury
Hyponatremia Correction in Hepatic Encephalopathy
- Slow correction: Prevents rapid shifts in brain water, preventing cerebral edema
Sphincter of Oddi Function
- Controls bile flow: From common bile duct into duodenum
Liver Synthetic Function Tests
- Reflects function: Prothrombin time (PT) and INR
- Reflects function: Albumin levels
AST and ALT Levels in Alcoholic Liver Disease
- Potential indication: AST levels 2-3 times higher than ALT levels
Liver Injury Markers
- Most specific: Alanine aminotransferase (ALT)
LDH Elevation Causes
- Liver damage: Due to cell death and release of LDH
- Muscle injury: Due to muscle damage releasing LDH
Alkaline Phosphatase Correct Statements
- Elevated in: Cholestasis and bone disease
- Not specific: Can be raised by various conditions
Elevated Bilirubin Levels
- Indication: Liver dysfunction or blockage of bile flow
Liver Function Tests (LFTs) Performance
- Can't diagnose: Specific liver diseases, only suggest problems
Hepatic Artery Buffer Response (HABR)
- Caused by: Increased portal pressure, triggers hepatic artery dilation
Liver's Major Component
- 80% of mass: Hepatocytes
Portal Vein Pressure
- Average: 5-10 mmHg
Liver Cell Regulating Vascular Tone
- Primarily involved: Ito cells
Sympathetic Nervous System Stimulation on Hepatic Blood Flow
- Effect: Decreases blood flow
Gluconeogenesis
- Conversion of: Lactate, glycerol, and amino acids into glucose by the liver
Liver Hemorrhage Tolerance
- Contribution: Vasoconstriction and increased glucose production
Elevated Liver Enzymes Cause
- Most common in adults: Non-alcoholic fatty liver disease (NAFLD)
NAFLD Treatment
- Recommended: Lifestyle modifications (diet and exercise)
Elevated Alkaline Phosphatase and Transaminases
- Indication: Cholestasis, possible biliary tract disease
Increased Vd of Drugs in Liver Disease
- Complications: Decreased albumin binding, increased free drug
Midazolam in Liver Disease
- Consideration: Requires dose adjustment due to prolonged duration
Aspiration Risk in Anesthesia Induction
- Increase: Reduced gastric emptying and delayed gastric emptying
Best Anesthetic Agent for Liver Disease
- Often preferred: Propofol due to short duration and fast elimination
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Description
Explore the intricacies of liver anatomy, including the division into lobes and classification systems like Couinard. Learn about the hepatic artery, portal vein, and their roles in supplying blood to the liver. This quiz is essential for understanding liver function and surgical classifications.