Perioperative medicine in ACP 2013....liver disorders

You are asked to see a 54-year-old man for preoperative risk assessment. He is being considered for repair of an umbilical hernia. He has been told he has liver problems in the past secondary to alcohol abuse and chronic hepatitis C, but he has not sought medical care in several years. He denies the use of alcohol for the past 5 years. He takes no medications.
On examination, his blood pressure is 105/77 mm Hg, his pulse is 92 and regular. He is alert and oriented with mild scleral icterus. Gynecomastia and spider angiomata are noted. His abdomen is protuberant with a large umbilical hernia and possible ascites; no hepatomegaly or splenomegaly noted. His neurologic examination is normal.
His laboratory tests reveal Sodium 133 mmol/L, Creatinine 1.9 mg/dL, Total Bili 2.3 mg/dL, INR 2.2, Albumin 2.7 g/dL, Platelets 110,000.
An ultrasound of the abdomen reveals a cirrhotic liver with moderate ascites.
His Child-Turcotte-Pugh (CTP) score is class C; Model for End-Stage Liver Disease (MELD) score is 21.
What should you recommend?

1. Give fresh frozen plasma (FFP) and proceed with surgery
   
2. Give oral vitamin K for 3 days and proceed with surgery
   
3. Refer patient for consideration of a Transjugular Intrahepatic Portosystemic Shunt (TIPS) prior to
   surgery
   
4. Cancel surgery and refer patient for liver transplant evaluation
   

Correct Answer: D
Discussion:
Surgical procedures in patients with cirrhotic liver disease are associated with significant risk of morbidity and mortality. This risk is related to multiple issues including an increased propensity to infection, coagulopathy, hypoxia, hypotension, encephalopathy, difficulty with fluid management, organ failure and altered wound healing. Perioperative mortality can be estimated with the use of the Child- Turcotte-Pugh (CTP) classification and the Model for End-Stage Liver Disease (MELD) scoring system. Both scoring systems have been good predictors of 30-day mortality postoperatively. The CTP classification system incorporates the presence of encephalopathy and ascites, in addition to laboratory values such as bilirubin, albumin and INR. The general surgical 30-day mortality estimates are 10% for CTP class A, 31% for CTP class B and 76% for CTP class C. The MELD score, which is felt to be more precise, is calculated using the INR, serum total bilirubin and serum creatinine concentration. The 30-day mortality rises linearly by 1% for each MELD point below 20 and 2% for higher scores. For this patient with a MELD score of 25, his 30-day postoperative mortality is estimated to be 35%, which would be excessive risk for an elective surgical procedure for umbilical hernia repair, a surgery which would otherwise be low risk in a patient without liver disease. This patient should not have any elective surgery at this time; he should be referred for evaluation for liver transplantation. Although some data have suggested potential benefit of TIPS procedure prior to specific surgeries in patients with portal hypertension, existing guidelines do not recommend the use of TIPS preoperatively given limited data. This patient does have a coagulopathy which might respond somewhat to the use of vitamin K (or transiently to FFP), however, improving his INR somewhat would not reduce overall surgical risk significantly.

 Clinical Pearl: Patients with significant liver disease should be referred for liver transplant evaluation prior to elective surgery.

References:

1. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;132:1261-9.
   
2. Nicoll A. Surgical risk in patients with cirrhosis. Journal of Gastroenterology and Hepatology 2012;27:1569–75
   
3. Online MELD calculator: http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98