Liver Disease
ASSESSMENT
Data Gathering
History
Symptoms
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Chronic liver disease: previous work-up (ultrasound, CT, liver biopsy), previous antiviral treatment (HBV/HCV)
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History of substance abuse
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History of Tylenol use
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Previous complications of liver disease (encephalopathy, GI varices/bleeding, ascites)
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Abdominal pain
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N/V
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GI bleeding
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Edema
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Increased abdominal girth
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Lethargy/confusion
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Easy bleeding/bruisability
Exam
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Ascites
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Spider angiomata
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Palmer erythema
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Asterixis
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Edema
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Altered mentation
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Splenomegaly
Risk Stratification
Diagnostic Studies
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Complete metabolic panel (including hepatic function panel), INR, and CBC within 4 months (sooner if any recent clinical change)
Elevated LFTs/Undiagnosed Liver Disease
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If history or exam suggest possible liver disease, check liver transaminases, bilirubin, albumin and INR
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If ALT/AST elevated >3x normal or any elevation with elevated bilirubin, surgery should be delayed for further hepatic evaluation (Hanje et al)
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Up to 30% of such patients have cirrhosis (Hay et al)
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Lesser abnormalities without cirrhosis or portal hypertension are likely low-risk for perioperative complications (Brolin et al, Kim et al)
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Viral Hepatitis
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If acute, carries high risk for complications & surgery should be delayed (Im et al)
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If chronic, minimal risk unless symptomatic or with evidence of synthetic dysfunction (low albumin), cirrhosis, or portal hypertension
Obstructive Jaundice
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Carries high risk for complications & surgery should be delayed (Im et al)
Cirrhosis
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Risk estimation can be done using calculator:
MANAGEMENT
Indications for Surgical Delay
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Transaminases >3x normal or any elevation with elevated bilirubin or findings of portal hypertension (Hanje et al)
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Acute viral hepatitis or obstructive jaundice (Im et al)
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Decompensated cirrhosis (Northup et al)
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Cirrhosis with MELD >15 (Im et al, Northup et al)
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Ascites and planned abdominal surgery (Northup et al)
Preoperative Management
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For patients with cirrhosis, perform surgery at center with hepatology and surgical expertise with cirrhotic patients
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Optimize/stabilize all sequelae of liver disease (Northup et al): encephalopathy, ascites, variceal bleeding risk, and electrolyte imbalances​
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If significant ascites present, perform large volume paracentesis with provision of 6-8 g of IV albumin per liter of fluid removed​ (Northup et al)
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If documented cirrhosis and not up-to-date with esophageal varices surveillance, address this before non-urgent surgery (Northup et al)
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Thrombocytopenia/coagulopathy (ISTH Recommendations)
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Do NOT obtain PT/INR, APTT, platelet count, & fibrinogen routinely to predict bleeding risk prior to procedures, even in critically ill
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Evaluate for other causes of thrombocytopenia if platelet counts less than 30,000
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Do NOT provide treatment for thrombocytopenia (including platelet transfusion & thrombopoietin receptor agonists) prior to surgery except for very high bleeding risk procedures (intraocular & spinal/cranial surgery)
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For very high bleeding risk procedures:
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Provide platelet transfusions (1 hour before) in non-elective cases or elective cases when thrombopoietin receptor agonists are unavailable or unsuitable.
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Thrombopoietin receptor agonists may be considered if:
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Platelet count 30,000-50,000
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No history of or risk factors for arterial or venous thrombosis
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Postoperative Management (Northup et al)
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Consult hepatology for co-management
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Avoid NSAIDs
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Use acetaminophen cautiously and avoid acetaminophen-containing opioid combinations
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Minimize sedation
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Use opioids with caution; avoid long-acting opioids​
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Use benzodiazepines with caution and only use short-acting forms
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Aggressively prevent constipation with lactulose, polyethylene glycol, and/or rifaximin (to reduce encephalopathy)
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Tight intravascular volume management (hypervolemia worsens portal hypertension and hemorrhage risk; hypovolemia worsens encephalopathy)
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Continuation/resumption of diuretics and IV fluids must be determined on individualized basis​
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Monitor BMP and LFTs daily in hospital
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Provide VTE prophylaxis (cirrhosis patients have increased VTE risk as well as increased bleeding risk)
COUNSELING & COMMUNICATION
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Collaborate with patients' hepatologists
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Fully advise cirrhotic patients of their perioperative risks and assure full consideration of surgical alternatives