CIRRHOSIS

D&NH: Final common pathway for a variety of chronic liver diseases characterized by fibrosis, nodule formation, irreversibility. Decompensated cirrhosis gives clinical complications as a result of portal hypertension and impaired synthetic function = ascites, jaundice, encephalopathy, variceal bleeding. Decompensation = poor prognosis from the start Acites = 50% 2 year mortality Variceal bleed = 50% 1 year mortality SBP = 20-40% in hospital, 70% at 1 year Type 1 HRS = 50% at 2 weeks

E&F: Incidence of 3.5-5%. Occurs in 10-15% of heavy drinkers. Ae&RF: 1. HCV 2. Alcohol 3. NAFLD HCV: RNA flavivirus. Leads to chronic hepatitis in 85%. o Persistent anti-HCV antibodies, serum viral proteins and HCV RNA o HCC in 1-4% o Good initial graft rates but virtually all become reinfected with HCC after transplant HBV: hepadnavirus, persistent HBV DNA and HBV antigen in serum o Rx with recombinant interferon -2b (40% remission) o Infection attack against HBV antigens on hepatocyte surface cirrhosis o 25-30 year latency for HCC o Post-transplant prophylaxis with high-titre hep B immunoglobulin or antiviral therapy Toxins: alcohol o Injury from toxic effects of ethanol on hepatocytes, accumulation of fatty acids and subsequent degeneration and necrosis Autoimmune: lupoid hepatitis Metabolic: Wilsons, alpha-1-antitrypsin deficiency, haemochromatosis Prolonged cholestasis: intra- and extrahepatic Path: Micronodular in alcohol, macronodular in viral. Effect of surgery o Decreased hepatic perfusion Anaesthetic agents decrease perfusion by 30-50% Invasive positive pressure ventilation Pneumoperitoneum Abdominal visceral traction (reflex splanchnic vasodilation) Ascites o Pulmonary effects: hypoxia Hepatopulmonary syndrome Portopulmonary hypertension

 Hydrothorax o Portal hypertension Systemic and splanchnic vasodilation vasoconstrictor systems and increased renal sensitivity to vasocontrictors renal vasoconstriction bleeding, ascites, renal failure Child-Turcott-Pugh Classification Initially designed to predict mortality after portocaval shunting, applicable to wide range of operation A: 5-6, 0-5% mortality (10%) B: 7-9, 10-15% mortality (30%) C: 10-15, >25% mortality (80%) 1 <34 <28 <4 < 1.7 2 Mild Controlled 34-50 mg/dL 28-34 4.1-6 1.7-2.3 3 Refractory Refractory >50 >34 >6 > 2.3

Ascites Encephalopathy Bilirubin Albumin PT INR

MELD Score Relies on INR, bilirubin and creatinine. An objective measure, no arbitary cutoffs Linear risk increase in 1 gives 14% increase in mortality Utility o Survival post-TIPS o Mortality any liver aetiology o Prioritse organ allocation o Mortality in non-hepatic surgery MELD score <7 8-11 12-15 16-20 21-25 >25 30 day mortality 6% 11% 25% 44% 54% 90%

Age + ASA are additional independent risk factors MELD > 13 poor prognosis

Clinical: Most cirrhotics are asymptomatic Fatigue, weight gain, abdominal distention, pruritus, jaundice Palmar erythema, clubbing, bruising, parotidomegaly, scleral icterus, jaundice, spider naevi, gynaecomastia, caput, distended abdo wall veins, testicular atrophy, splenomegaly, hepatomegaly, abdominal ascites, peripheral oedema, pleural effusion

Ix/Dx/Work-up: FBC: anaemia, THROMBOCYTOPENIA (usually >50), leucopenia Coags: prolonged PT LFT, bilirubin (>30 severe dysfunction (excl. transfusion) Albumin Perc liver biopsy (if no ascites/coagulopathy) Radiology: nodular liver, recanalisation umbilical vein Operative Recommendations 1. Acute hepatitis postpone elective surgery until liver tests have normalized 2. Chronic hepatitis generally safe for elective surgery 3. Childs A: elective surgery tolerated 4. Childs B: permissible in some cases. Treat ascites and coagulopathy and can then proceed. No portal hypertension. Caution cardiac or hepatic resection. 5. Childs C elective surgery contraindicated. postpone until improved class, or non-operative management Pre-operative Treat reversibility o Alcohol abstinence > 6/52 o HBV anti-viral (aim low to undetectable HBV DNA) Closely monitor and treat o Ascites o Infection o Renal impairment Early involvement with hepatologist Post-operative INR best predictor of function Bilirubin Hypoglycaemia Hepatic encephalopathy Volume status: maintain intravascular volume in face of extravascular overload and avoidance of salt loading

Common situations in ESLD

Umbilical hernia Occurs in 20% with ascites Spontaneous rupture increases mortality and is most feared complication o If occurs requires prevention of treatment and fluid/electrolyte management Management 1. Non-operative a. Elastic binder b. Ascites reduction can minimize symptoms c. TIPS may control symptoms, or optimize ascites pre-operatively

2. Operative a. Primary hernia repair, avoid mesh i. Needs aggressive pre-op reduction of ascites in elective setting 1. 73% recurrence in presence of ascites 2. 14% recurrence without ascites ii. Consider concomitant/staged TIPS/peritoneovenous shunting b. (TIPS) c. Liver transplant with concomitant or staged umbilical hernia repair Groin hernias less risky for mortality and recurrence Indications for surgery Skin changes: ulceration/black discolouration/crusting Incarceration/strangulation/perforation Complications 14% mortality Decompensation in 20% patients with abdominal surgery ascites, coagulopathy, haemodynamic instability, renal failure, death Recurrence