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.