Liver Disease

ASSESSMENT

Data Gathering

History

Symptoms

  • Chronic liver disease: previous work-up (ultrasound, CT, liver biopsy), previous antiviral treatment (HBV/HCV)

  • History of substance abuse

  • History of Tylenol use

  • Previous complications of liver disease (encephalopathy, GI varices/bleeding, ascites)

  • Abdominal pain

  • N/V

  • GI bleeding

  • Edema

  • Increased abdominal girth

  • Lethargy/confusion

  • Easy bleeding/bruisability

Exam

  • Ascites

  • Spider angiomata

  • Palmer erythema

  • Asterixis

  • Edema

  • Altered mentation

  • Splenomegaly

Risk Stratification

Diagnostic Studies

  • Complete metabolic panel (including hepatic function panel), INR, and CBC within 4 months (sooner if any recent clinical change)

Elevated LFTs/Undiagnosed Liver Disease

  • If history or exam suggest possible liver disease, check liver transaminases, bilirubin, albumin and INR

  • If ALT/AST elevated >3x normal or any elevation with elevated bilirubin, surgery should be delayed for further hepatic evaluation (Hanje et al)

    • Up to 30% of such patients have cirrhosis (Hay et al)

    • Lesser abnormalities without cirrhosis or portal hypertension are likely low-risk for perioperative complications (Brolin et al, Kim et al)

Viral Hepatitis

  • If acute, carries high risk for complications & surgery should be delayed (Im et al)

  • If chronic, minimal risk unless symptomatic or with evidence of synthetic dysfunction (low albumin), cirrhosis, or portal hypertension

Obstructive Jaundice

  • Carries high risk for complications & surgery should be delayed (Im et al)

Cirrhosis

  • Etiology has relatively little impact on perioperative risk (Im et al)

  • Type of surgery has major impact on perioperative risk (Im et al):

Cirrhosis surgical risk.jpg
  • Risk estimation can be done using calculator:

MANAGEMENT

Indications for Surgical Delay

Preoperative Management

  • For patients with cirrhosis, perform surgery at center with hepatology and surgical expertise with cirrhotic patients

  • Optimize/stabilize all sequelae of liver disease (Northup et al): encephalopathy, ascites, variceal bleeding risk, and electrolyte imbalances​

    • 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)

    • If documented cirrhosis and not up-to-date with esophageal varices surveillance, address this before non-urgent surgery (Northup et al)

  • Thrombocytopenia/coagulopathy (ISTH Recommendations)

    • Do NOT obtain PT/INR, APTT, platelet count, & fibrinogen  routinely to predict bleeding risk prior to procedures, even in critically ill

    • Evaluate for other causes of thrombocytopenia if platelet counts less than 30,000

    • 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)

    • For very high bleeding risk procedures:

      • Provide platelet transfusions (1 hour before) in non-elective cases or elective cases when thrombopoietin receptor agonists are unavailable or unsuitable.

      • Thrombopoietin receptor agonists may be considered if:

        • Platelet count 30,000-50,000

        • No history of or risk factors for arterial or venous thrombosis

Postoperative Management (Northup et al)

  • Consult hepatology for co-management

  • Avoid NSAIDs

  • Use acetaminophen cautiously and avoid acetaminophen-containing opioid combinations

  • Minimize sedation

    • Use opioids with caution; avoid long-acting opioids​

    • Use benzodiazepines with caution and only use short-acting forms

  • Aggressively prevent constipation with lactulose, polyethylene glycol, and/or rifaximin (to reduce encephalopathy)

  • Tight intravascular volume management (hypervolemia worsens portal hypertension and hemorrhage risk; hypovolemia worsens encephalopathy)

    • Continuation/resumption of diuretics and IV fluids must be determined on individualized basis​

  • Monitor BMP and LFTs daily in hospital

  • Provide VTE prophylaxis (cirrhosis patients have increased VTE risk as well as increased bleeding risk)

COUNSELING & COMMUNICATION

  • Collaborate with patients' hepatologists

  • Fully advise cirrhotic patients of their perioperative risks and assure full consideration of surgical alternatives