Chronic Hepatitis
The extent of anesthetic or surgical risk imposed by chronic forms
of hepatitis primarily relates to the severity of associated hepatic synthetic dysfunction.
Runyon[104]
retrospectively studied 20 asymptomatic
patients who had chronic hepatitis B or C and were undergoing general or spinal anesthesia
for a total of 34 surgical procedures, most of which were at operative sites distant
from the liver. Liver enzyme test results did not worsen postoperatively, nor did
any patient experience postoperative liver failure or death. More recently, Higashi
and colleagues[105]
assessed the postoperative outcomes
of 119 patients with chronic hepatitis who were undergoing liver resection for primary
hepatocellular carcinoma (HCC). Patients with the most impaired liver enzyme test
results had a higher incidence of hepatic failure, recurrent HHC, and death.[106]
It would therefore appear that asymptomatic patients with any
form of chronic hepatitis should be screened before elective surgery for evidence
of hepatic dysfunction,
TABLE 55-1 -- Modified Child-Pugh scoring system
|
Modified Child-Pugh Score
*
|
|
Parameters |
1 |
2 |
3 |
|
Albumin (g/dL) |
>3.5 |
1.8–3.5 |
<2.8 |
|
Prothrombin time |
|
|
|
|
Seconds prolonged |
<4 |
4–6 |
>6 |
|
International normalized ratio |
<1.7 |
1.7–2.3 |
>2.3 |
|
Bilirubin (mg/dL)
†
|
<2 |
2–3 |
>3 |
|
Ascites |
Absent |
Slight-moderate |
Tense |
|
Encephalopathy |
None |
Grade I–II |
Grade III–IV |
|
From Pugh RNH, Murray-Lyon IM, Dawson JL, et al:
Transection of oesophagus for bleeding of oesophageal varices. Br J Surg 60:646–649,
1973. |
*Class
A = 5.6 points, B = 7 to 9 points, and C = 10 to 15 points.
†For
cholestatic diseases (e.g., primarily biliary cirrhosis), the bilirubin level is
disproportionate to the impairment in hepatic function, and an allowance should be
made. For these conditions, assign 1 point for a bilirubin level less than 4 mg/dL,
2 points for a bilirubin level of 4 to 10 mg/dL, and 3 points for a bilirubin level
over 10 mg/dL.
with the INR being the most sensitive indicator of the severity of hepatocellular
dysfunction. When surgery cannot be avoided, meticulous care should be taken perioperatively
to maintain hepatic perfusion and avoid factors that might precipitate liver failure,
hepatic encephalopathy, or both (see later).
