Hepatobiliary.pdf

Hepatobiliary Evaluation Health Assessment Liver Disease Impacts Hepatocytes Biliary system Or both Protein synthesis (albumin and clotting factors) Bile regulation Metabolism of drugs/toxins Hepatocellular Disease Hepatitis Viral Alcoholic Autoimmune Hepatocellular carcinoma Impact hepatocytes and...

Hepatobiliary Evaluation Health Assessment Liver Disease Impacts Hepatocytes Biliary system Or both Protein synthesis (albumin and clotting factors) Bile regulation Metabolism of drugs/toxins Hepatocellular Disease Hepatitis Viral Alcoholic Autoimmune Hepatocellular carcinoma Impact hepatocytes and synthetic function of liver Obstructive Disorders Choleodocholithiasis Bile duct tumors (extrahepatic) Primary biliary cirrhosis (intrahepatic) Primary sclerosing cholangitis (extra and intrahepatic) All impact bile stasis Patient History Underlying etiology, therapies, associated complications Explore degree of liver disease and cause Fatigue, weigh loss, dark urine, pale stools, pruritus, RUQ pain, bloating, jaundice Rule out encephalopathy, coagulopathy, ascites, volume overload New onset or worsening encephalopathy warrants further workup Physical Exam Daily/recent weights Presence of jaundice Bruising Ascites Pleural effusions Peripheral edema Hypoxia Bilirubin must be over 2.5 mg/dL to see jaundice (icterus) in mucous membranes Testing/Evaluation EKG CBC with platelet count LFTs Albumin PT Based on history, may include Hepatitis, ammonia, CXR Hepatitis Testing Hepatitis A Hepatitis A immunoglobulin M (IgM) antibody Hepatitis B Surface and core antigens Hep B surface antibody Hepatitis C Hep C antibody Coagulopathy Three main causes Vitamin K deficiency (cholestasis) Factor deficiency (loss of synthetic function) Thrombocytopenia (splenomegaly and portal hypertension) Correct pre-operative coagulopathy, based on cause Vitamin K 1-5mg orally/SQ for at least 3 days FFP if factor etiology Platelets if thrombocytopenia Don’t forget about TEG Risk Reduction Correct ascites Wound healing Improved pulmonary function Correct encephalopathy Lactulose 30ml every 6 hours, last dose at least 12 hours before surgery Rule out causative factors (infection, GI bleed, hypovolemia, sedatives Sodium restriction Reduce volume overload Potentially delay elective surgery in the face of acute hepatitis or encephalopathy Predictors of Poor Outcome Child-Turcotte-Pugh class C cirrhosis MELD score 15 or greater Serum bilirubin, IRN, serum creatinine Acute hepatitis Chronic active hepatitis with jaundice, encephalopathy, coagulopathy, or elevated LFTs Abdominal procedures PT > 3 seconds refractive to vitamin K Child-Turcotte-Pugh (cirrhosis classification) MELD Score (model for end-stage liver disease) Survivability based on MELD score Obstructive Jaundice Extrahepatic bile duct obstruction Gallstones Tumors Pancreatic Gallbladder Bile duct Ampulla of Vater Scarring Perioperative AKI occurs in 8% of these patients Prevention with bile salts or lactulose Obstructive Jaundice Present with Jaundice Pruritus Abdominal pain Predictors of poor outcome Hemoglobin < 10 g/dL Serum bilirubin > 20 mg/dL Serum albumin < 2.5 g/dL Cirrhosis End result of hepatic conditions Leads to portal hypertension Splenomegaly Esophageal varices Ascites Dependent edema Pleural effusions Impaired synthetic and metabolic processes Jaundiced patients are at risk of hepatorenal syndrome Cirrhosis ESLD patients develop high cardiac output state Increased CO Decreased SVR Leads to heart failure Unexpected High LFTs Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) à damage to hepatocytes Think hepatitis Bilirubin à ability to conjugate and excrete bile Think obstruction Alkaline phosphatase (ALP) à impaired hepatic excretion Think obstruction Albumin or PT à synthetic function Think hepatocyte damage/injury Abnormal LFTs signals further workup