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Flashcards in paracetamol overdose Deck (39)
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1

what is the cause of death in PO?

cell death caused by necrosis from a toxin - the clinical effects therefore come from the loss of function of cells

2

why may the effects of PO vary?

it depends on the proportion of cells that are affected and the function remaining to meet the demand of the organ

3

what is another name for paracetamol?

acetaminophen

4

what is the prevalence of PO?

48% of all medical admissions and 10000 per year
the commonest cause of medical admissions in under 40s
leading cause for liver failure acutely

5

what is the affect of PO?

causes severe injury to the liver, abdo pain, very unwell after 40 hours

6

how would you identify the cause?

the social and medical history
if alcohol then take the amount and the strength to calculate the units

7

what is the relationship between strength and units?

1 litre of the APV = the number of units

8

how may PO cases present?

comatosed, acidotic, renal failure, clotting disturbance, ALT far higher than usual such as 1500 when should be <35

9

what ligaments are in the liver?

the falciform anteriorly separating the left and right loves, the teres posteriorly, the right and left triangular and the coronary ligament posteriorly

10

what does the gall bladder feed into?

the common bile duct

11

what is the lobe inferior to the gall bladder?

the quadrate lobe - the caudate is superior to this

12

what is the exit for the HAP, and PV?

the porta hepatis

13

what comes off the IVC?

the hepatic veins

14

what is the structure of the liver?

it is the largest organ in the body weighing around 1.2-1.5kg and is 2.5% of the body mass. There are two blood supplies from the gut and the artery

15

outline the blood supplies to the liver?

the portal vein comes from the gut and carries 2/3 volume but low pressure blood, the blood from the hepatic artery is oxygenated and higher pressure

16

why is two supplies beneficial?

it is less susceptible to ischaemia

17

what are the metabolic functions and some examples of the liver?

carbohydrate (glycogenesis), fat (triglyceride and lipoprotein), amino acid metabolism, protein and amino acid synthesis (albumin, CRP), hormones and prohormones (angiotensin), detoxification (alcohol, medication, drugs, chemicals), activation of drugs and bilirubin metabolism

18

what other functions does the liver have?

barrier to sepsis and vitamin A, D and B12 and iron storage

19

what is the histological structure of the liver?

the blood runs along sinusoids into the hepatic vein, the cells are square shaped and the hepatocytes are close to a blood supply, there is lots of mitochondria, ER and cytoplasm for lots of enzymes

20

how can liver be affected by drugs?

there are two ways:
intrinsic - everyone will react in the same way - will damage all livers in high volumes
idiosyncratic - unexpected and uncharacteristic - most reactions - rare and unpredictable

21

what are the differences between individuals metabolism?

the liver has evolved to detoxify the blood and make toxins safe, then excrete them. There are many different enzymes and metabolic pathways and people differ in the way that they metabolise things

22

how does paracetamol metabolism work?

it is attached to sulphuric acid which makes it water soluble and then excretes it by the kidneys or is conjugated with glucuronide. A minor pathway will metabolise paracetamol when a large amount is taken

23

what causes damage in overdose?

NAPQI

24

how can NAPQI cause damage?

the ability to detoxify NAPQI is overwhelmed. This means that it cannot be turned into cysteine and mercapturic acid conjugates and that it builds up and attaches to cell proteins to cause damage

25

what is the reaction for paracetamol metabolism?

paracetamol will be conjugated wither into sulfate or glucuronide. If not it will go through the P450 pathway and make N-acetyl-p-benzoquinoneimine which is toxic. This with glutathione will make cysteine and mercapturic acid conjugates which are non toxic

26

what is the mechanism of cell death in viral hepatitis and what does it look like?

apoptosis - controlled and programmed - occasional dead cells with dense pink cytoplasm and small nucleus

27

what is the mechanism of death in PO and what does it look like?

confluent necrosis - uncontrolled - lost all proteins, pink - hepatocytes first as these have the enzymes that metabolise paracetamol

28

what causes acute liver failure?

over 50% of cells with a loss of function/death

29

which liver cells die first?

the zone 3 ones as they contain the metabolising enzymes

30

what are the effects of cell death in the liver?

amino transferase enzymes will peak at around 1000-3000
jaundice - cannot process bilirubin
coma - failure to detoxify nitrogenous compounds
bleeding - failure to synthesis proteins and clotting factors
renal failure - lower glomerular filtration due to shock - hepatorenal syndrome