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EVALUATION/RISK FACTORS

Introduction

Liver disease may range from acute hepatic injury/hepatitis to chronic liver disease, which itself includes the spectrum of hepatic dysfunction to hepatic fibrosis or cirrhosis before progressing to end-stage liver disease and liver failure. Multiple liver disease etiologies exist, including viral, metabolic, autoimmune, or toxin/medication including alcoholic liver disease. One and a half million people worldwide have chronic liver disease, with nonalcoholic fatty liver disease (NAFLD) now the most common etiology (60%); hepatitis B vaccination and effective hepatitis C treatment have contributed to shifting epidemiology.1 With improved survival, more patients with chronic liver disease may present for surgical care and with more comorbidities.

Liver disease, especially cirrhosis and end-stage liver disease, is clearly associated with increased risk of perioperative morbidity and mortality. The liver maintains vital roles in homeostasis, and impairment of these roles can have significant adverse effects in the perioperative and intraoperative setting. Additionally, extrahepatic manifestations and complications of liver disease drive the risk of specific perioperative complications.

Patient-Related Risk Factors

A comprehensive history and physical is a crucial element of a preoperative assessment. If liver disease is present, the extent of hepatic injury/dysfunction and known hepatic or extrahepatic complications such as a history of decompensation must be assessed (e.g., ascites control, degree of encephalopathy, history of spontaneous bacterial peritonitis, variceal bleeding, hepatorenal syndrome, hepatocellular carcinoma). The past medical history and social history may reveal risk factors for undiagnosed liver disease (e.g., intravenous drug use, alcohol misuse, metabolic syndrome, birth in endemic countries, sexual history, history of blood transfusions).

The physical exam may prompt concern for undiagnosed liver disease, revealing ascites, hepatomegaly, splenomegaly, lower extremity edema, or dermatologic manifestations (jaundice, scleral icterus, spider telangiectasias, palmar erythema, gynecomastia, caput medusa). In a patient with known liver disease, the examination should assess the presence or control of ascites, lower extremity edema, and asterixis.

Liver disease severity can be assessed via the Child-Turcotte-Pugh (CTP) or Model for End-Stage Liver Disease (MELD) calculators (Table 25-1). The MELD is a logarithmic function of INR, serum BR, serum creatinine; serum sodium was added in 2016. The iMELD further incorporates age into the MELD.

TABLE 25-1Scoring System for Child-Turcotte-Pugh (CTP) Class

Perioperative evaluation of patients with liver disease must also include assessment of other comorbid conditions such as diabetes, cardiovascular disease, and chronic kidney disease.

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