© 2018 Kurt Pfeifer.

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 based upon MELD classification system, but may underestimate risk in patients with ascites or encephalopathy. Also, for any estimated level of risk, an albumin >2.5 g/dl indicates lower risk.

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 - manage the same as for the general population (see Hematologic Disease section)​

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