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Chapter: Clinical Cases in Anesthesia : Liver Disease

List the causes of postoperative hepatic dysfunction

Numerous etiologies of hepatic dysfunction occur post-operatively. It is important to establish the cause quickly and to initiate therapy as soon as possible.

List the causes of postoperative hepatic dysfunction.

 

Numerous etiologies of hepatic dysfunction occur post-operatively. It is important to establish the cause quickly and to initiate therapy as soon as possible. Three major concerns are bilirubin overload, hepatocellular injury, and cholestasis. A common cause of postoperative jaundice is a relative overproduction of bilirubin from hemoglobin. This commonly results from blood transfusion reactions, hematoma resorption, and hemolysis. Old and damaged stored erythrocytes will break down and release hemoglo-bin. The liver easily handles small increases in bilirubin; however, if there is significant pre-existing hepatic disease or large amounts of blood are transfused, significant increases in unconjugated and conjugated bilirubin may result even with mild liver impairment secondary to anes-thesia. Similarly, hematoma resorption may also contribute to postoperative jaundice in a patient who has significantly bled into a limb, e.g., hip or femur fractures. Significant hemolysis from blood transfusion reactions can also result in jaundice. An increase in unconjugated bilirubin without increases in conjugated bilirubin suggests the presence of Gilbert syndrome, which is present in 7–10% of otherwise normal patients.

Persistent jaundice following surgery of the hepatobil-iary tree is usually an indication of retained common bile duct stones. Trauma to the bile duct during surgery may result in spasm and/or stenosis. High-dose fentanyl can, on rare occasions, result in sphincter spasm.

 

The most common abnormalities found on liver function tests performed postoperatively suggest that parenchymal liver cell damage is not a dominant feature. The mild degree of liver dysfunction probably reflects a nonspecific perioperative change in hepatic blood flow. Transient hepatic oxygen deprivation is common and usu-ally resolves without specific treatment. Some authorities believe that the minor transient alterations in liver func-tion tests are in fact manifestations of mild hepatotoxicity of a potent inhaled agent. Indeed, following exposure to halogenate anesthetics, transient elevations in liver transaminase levels are common. There are many reports of minor alterations in liver function tests even when intra-venous anesthetic techniques are used, and probably reflect the nonspecific perioperative changes in hepatic blood flow. It should be noted that a “shock liver” syndrome secondary to prolonged marked hypotension can occur.

 

In some patients postoperative liver dysfunction is the result of having pre-existing liver disease that only becomes evident after surgery. The manifestations of overt disease, which both the patient and the clinician may have been unaware of preoperatively, may be precipitated by the detrimental effects of decreased hepatic blood flow on liver function. Additionally, patients may be in a latent phase of an illness and postoperative liver dysfunction may be the result of the natural progression of the pre-existing liver disease.

 

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