11.7 Chronic Liver Disease Flashcards
A patient with end-stage chronic liver disease is listed for elective surgery under general anaesthesia.
a) List the common causes of chronic liver disease.
(3 marks)
Most common:
» Alcoholic liver disease.
> > Non-alcoholic fatty liver disease
(caused by obesity, diabetes).
> > Viral hepatitis, B and C.
Also:
» Autoimmune causes:
primary biliary cholangitis,
sclerosing cholangitis.
> > Metabolic disease:
Wilson’s, haemochromatosis,
alpha-1-antitrypsin deficiency.
> > Toxins, drugs.
> > Right heart failure
b) Explain which systemic effects of chronic liver disease are of importance to the anaesthetist and why. (9 marks)
A-D
Airway: *
» Risk of reflux due to raised
intra-abdominal pressure due to ascites.
Rapid sequence induction and
premedication with proton pump inhibitor
required
Respiratory:
» Diaphragmatic splinting due to ascites,
resulting in basal atelectasis,
V/Q mismatch,
reduced functional residual capacity.
May require paracentesis,
sodium and water restriction
preoperatively in order to
improve ventilatory mechanics.
> > Pleural effusions can impact
on lung expansion,
impairing gas exchange.
May need to be drained preoperatively.
> > Hepatopulmonary syndrome:
pulmonary arteriovenous malformations
causing right-to-left shunt.
Results in hypoxia that cannot be corrected
by administration of oxygen.
____________________________________
Cardiac:**
» Hyperdynamic circulation with
high cardiac output,
low blood pressure
and low systemic vascular resistance (SVR)
(portal hypertension triggers excessive
vasodilatory mediator action in peripheral
and splanchnic circulation).
> > Portopulmonary hypertension,
cirrhotic cardiomyopathy and
pericardial effusion may all increase
cardiovascular instability under anaesthesia.
> > Low SVR may mask
underlying coronary artery disease.
> > Echocardiogram useful in demonstrating
effects of cirrhotic cardiomyopathy,
portopulmonary hypertension
and pericardial effusion.
Cardiological input may be required preoperatively.
> > Invasive blood pressure and
cardiac output monitoring can help optimise fluid and vasopressor use.
____________
Neurological:
» Hepatic encephalopathy.
May be precipitated by gastrointestinal bleed,
infection, sedative drugs, hypoglycaemia, excessive protein intake, hypotension, hypoxia.
Ensure gas exchange is monitored and hypoxia
appropriately managed; avoid long-acting sedative drugs.
> > Wernicke’s encephalopathy due to
thiamine deficiency associated with
alcoholic liver disease.
Ensure thiamine supplementation from the time of
admission, intravenously if necessary
b) Explain which systemic effects of chronic liver disease are of importance to the anaesthetist and why. (9 marks)
G-M
Gastrointestinal:
» Risk of varices and gastric erosions,
associated with blood loss.
Ensure full blood count checked;
oesophageal Doppler contraindicated in the
presence of varices.
Haematological:
» Anaemia due to chronic blood loss from gastrointestinal tract,
hypersplenism-induced haemolysis,
chronic illness, malnutrition.
Check full blood count and
haematinics if indicated.
Ensure anaemia is adequately
treated preoperatively.
> > Coagulopathy due to failure to
synthesise clotting factors.
Regional anaesthesia may be contraindicated.
Clotting factor supplementation
may be required; seek senior haematological advice.
> > Thrombocytopaenia and platelet dysfunction. May contraindicate regional anaesthesia.
Platelet supplementation may be required to facilitate
surgery.
Immune, infection:
» Reduced immune function, infection prone.
Assess for the presence of infection
by checking for symptoms,
check white cell count,
investigate as appropriate.
Renal:
» Hepatorenal syndrome.
Avoid other renal insults in the perioperative
period such as hypotension,
dehydration, nephrotoxic drugs.
> > Secondary hyperaldosteronism
contributes to ascites, effusions
and peripheral oedema.
Patient may already be taking aldosterone
antagonists.
Metabolic:
» Depletion of hepatic and
muscle glycogen stores increases the risk
of hypoglycaemia.
Blood glucose must be monitored perioperatively,
especially when under general anaesthesia,
to avoid dangerously low glucose level. Supplementation may be required.
c) Outline the Child–Pugh scoring system and explain how this may be used to stratify mortality risk for
this patient. (8 marks)
Five variables
(bilirubin****
,albumin,
prothrombin time,
encephalopathy and
ascites)
are quantified and given
a score from 1 (least severe) to 3.
The numbers are added up to give a total.
Based on the total, the patient is
classified as Child’s A, B or C
(A being least severe).
Based on population studies,
an individual’s Child’s category
can be used to predict their overall
survival and also their likely mortality
associated with surgery.
Child Pugh in more detai
Here it is in more detail:
1 2 3
Bilirubin (mcg/l) <34 34–50 >50
Albumin (g/l) >35 28–35 <28
Prothrombin time (s>control) <4 4–6 >6
Encephalopathy 0 Mild (Grades I–II) Marked (III–IV)
Ascites None Mild Marked
Used as a risk prediction tool for patients
undergoing abdominal surgery:
Used as a risk prediction tool for patients
undergoing abdominal surgery:
<7 = Child’s A, <5% mortality
7–9 = Child’s B, 25% mortality
>9 = Child’s C, 50% mortality
Or just for assessing overall mortality risk:
One-year survival
A: 100%
B: 80%
C: 45%
