Acute Hepatitis
The diverse role of the liver in drug metabolism, hemostasis,
and coagulation function, in association with surgery and anesthesia-related alterations
in hepatic perfusion, make it an organ extremely susceptible to clinically important
viral-, alcohol-, or other drug-induced hepatocellular injury. Consensus opinion,
based largely on data derived from older, predominantly retrospective studies, is
that acute hepatitis, whether viral, alcohol, or drug induced, is a risk for the
development of hepatic failure or death after elective surgery. In 1982, Powell-Jackson
and coauthors[96]
described 36 patients who underwent
exploratory laparotomy for either suspected extrahepatic biliary tract obstruction
or intra-abdominal malignancy, all of whom were ultimately found to have viral or
alcoholic hepatitis, cirrhosis, or Budd-Chiari syndrome. Of these patients, 61%
suffered significant morbidity, including postoperative liver failure, and 31% died
within 1 month of surgery. One hundred percent of patients with histologically proven
hepatitis died. Greenwood and associates[97]
also
reported high mortality rates in patients with alcoholic hepatitis undergoing open
liver biopsy. Bell and colleagues,[98]
however,
noted that survival rates were not influenced by the presence of biopsy-proven hepatitis
in 164 patients with alcoholic cirrhosis requiring emergency portocaval shunts for
esophageal variceal bleeding.
In the current era of advanced diagnostic testing and imaging
where nonoperative management of extrahepatic biliary tract obstruction can be performed
with endoscopic retrograde cholangiopancreatography (ERCP), invasive procedures such
as open liver biopsy or exploratory laparotomy can be avoided. The preponderance
of previously described information regarding perioperative morbidity and mortality
indicates that elective surgery should be delayed in patients with acute hepatitis
of any etiology until resolution of hepatocellular dysfunction can be confirmed.
[51]
The influence of the type of surgery on patients
with hepatitis is described later.