Postoperative Liver Dysfunction
Last updated: 01/27/2023
- Postoperative liver dysfunction (POLD) is common after surgery, and jaundice (hyperbilirubinemia) is the most frequent sign.1
- Even healthy patients without prior history or symptoms of liver disease may exhibit abnormal liver function tests postoperatively.
- For patients with known underlying liver disease, postoperative jaundice occurs regularly and in severe cases, can lead to postoperative liver failure (POLF).
- Bilirubin is a byproduct of the breakdown of heme from red blood cells. Under normal conditions, the liver conjugates the bilirubin to make it water-soluble and secretes it into the gastrointestinal tract as bile. Jaundice, which is the result of hyperbilirubinemia, occurs when there is a breakdown anywhere along the normal bilirubin uptake, metabolism, or excretion processes.
- The combined stresses of anesthesia and surgery frequently produce some degree of hepatic dysfunction, often manifested as jaundice. At the mildest end of the spectrum, the POLD is short-lasting and leads to a mild elevation in bilirubin and liver enzyme levels, while at the most severe end, a sustained deterioration in the metabolic and synthetic functions of the liver culminating in postoperative liver failure.
- The effects of anesthesia and surgery often result in a fall in hepatic blood flow leading to a reduction in O2 delivery, which can be as much as 30-40%.2 It is thought that ischemia and the subsequent reperfusion injury is responsible for much of the POLD reported.
Causes of Postoperative Jaundice
- It is useful to categorize the causes of jaundice and liver dysfunction into three main groups: prehepatic, intrahepatic, and posthepatic.3
- Prehepatic jaundice usually arises when the quantity of heme delivered to the liver surpasses its ability to conjugate it all.
- This presents as an unconjugated hyperbilirubinemia that resolves fully over time.
- In most cases, the excess heme is produced by hemolysis following bleeding during surgery or the use of blood transfusions.
- Intrahepatic jaundice is due to either the hepatocyte’s inability to conjugate bilirubin (hepatocellular dysfunction), or obstruction of the intrahepatic bile ducts resulting in a failure to transport the bile out of the liver (as in cirrhosis).
- It usually presents as an increase in both conjugated and unconjugated bilirubin.
- Hepatocellular dysfunction can be a result of hepatocyte failure from either ischemic or drug-induced stresses.
- “Shock liver” – acute ischemic hypoperfusion and subsequent reperfusion injury – is a severe condition reflecting massive damage to hepatocytes from ischemia. It leads to a large increase in the level of tissue transaminases along with a similar rise in the international normalized ratio, reflecting a deterioration in the synthetic functions of the liver. Exposure to a variety of hepatotoxic drugs can cause a similar picture, often developing in the days after surgery and improving after cessation of the offending drug (e.g., acetaminophen, inhaled volatile agents, amoxicillin/clavulanate, amiodarone).
- Posthepatic jaundice is usually secondary to the surgery itself (where damage to the biliary system often requires endoscopic intervention to aid resolution).
- This presents with an obstructive jaundice picture (conjugated hyperbilirubinemia with mildly elevated transaminases and alkaline phosphatase).
- A common example would be bile duct stenosis following liver transplantation.
- Postoperative jaundice is often multifactorial in origin (Figure 1, Table 1).
Prevention and Management
- Patients should be properly assessed and investigated before selection.
- The most appropriate anesthetic technique considering the patient’s pre-existing condition is important.
- Management of POLD should focus on treating the underlying cause.
- Frequent monitoring of blood tests may be necessary.
- Find alternatives for any potentially hepatotoxic drugs
- Seek specialized advice for potential surgical problems
- Supportive care is often the only option until the liver is able to self-repair.
- Faust TW, Reddy KR. Postoperative jaundice. Clin Liver Dis. 2004;8(1):151-66. PubMed
- Cowan RE, Jackson BT, Grainger SL, et al. Effects of anesthetic agents and abdominal surgery on liver blood flow. Hepatology. 1991;14(6):1161-66. PubMed
- Fink SA. Approach to the patient with postoperative jaundice. In: UpToDate, Brown R (Ed), UpToDate, Waltham MA (Accessed July 10, 2022).
- Pandey CK, Nath SS, Pandey VK, et al. Perioperative ischaemia-induced liver injury and protection strategies: An expanding horizon for anaesthesiologists. Indian J Anaesth. 2013;57(3):223-9. PubMed
- Huang YQ, Wen RT, Li XT, et al. The protective effect of dexmedetomidine against ischemia-reperfusion injury after hepatectomy: A meta-analysis of randomized controlled trials. Front Pharmacol. 2021; 12:747911. PubMed
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