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Cirrhosis

I. Purpose

Patients with cirrhosis who require emergency general surgery have significantly higher morbidity and mortality rates than patients without cirrhosis[^1]. While data on outcomes and risk prognostication remain limited in this population, this document outlines perioperative management considerations for the cirrhotic patient.

II. Guideline

A. Initial Evaluation of the Cirrhotic Patient with EGS Pathology

  • Liver disease stratification scores

    • MELD 3.0: INR, total bilirubin, creatinine, albumin, sodium, age, sex
    • Child-Pugh: INR, total bilirubin, albumin, ascites, hepatic encephalopathy

  • Imaging review

    • Evaluate for sequelae of portal hypertension: abdominal wall varices, splenomegaly, ascites

  • Postoperative risk scores

    • Patients with MELD >20 or Child-Pugh class C have high risk of postoperative decompensation and death
    • No absolute cutoff excludes patients from surgery; individualized prognostication recommended
    • Risk calculators:

B. Preoperative Correction of Coagulopathy

  • INR

    • Do not reverse unless actively bleeding or on vitamin K antagonist[^3]

  • Platelets

    • No transfusion unless active bleeding or platelets <30,000[^4]
    • Hold DVT prophylaxis if platelets <50,000[^5]

  • Fibrinogen

    • Transfuse cryoprecipitate to maintain >100 before surgery or with active bleeding[^2][^3]

  • TEG (Thromboelastography)

    • Use if available to direct transfusions and minimize blood product use[^6]

C. Cholecystitis in the Cirrhotic Patient

  • Imaging

    • RUQ US may show wall thickening or pericholecystic fluid due to portal hypertension
    • HIDA scan if ultrasound/CT non-diagnostic[^7]
    • MRCP if HIDA is non-diagnostic or biliary obstruction is suspected

  • Treatment

    • MELD ≤13 or Child-Pugh A/B:

      • Antibiotics + laparoscopic cholecystectomy[^8][^9]

    • MELD >13 or Child-Pugh C or decompensated:

      • Do not offer cholecystectomy
      • Begin antibiotics
      • If no improvement, consult IR + GI for cholecystostomy vs advanced endoscopy[^8][^10]
        • Avoid percutaneous approach if ascites present

  • Transplant Surgery Referral

    • For patients listed for transplant, with history of HCC, or with a TIPS

D. Postoperative Management

  • Hepatic Encephalopathy

    • Resume home regimen if chronic
    • If new:
      • Check ammonia level (no need to trend)
      • Start lactulose 20g or 30mL PO BID–TID to 2–3 BMs/day[^11]
      • Add rifaximin 550mg PO BID if needed
      • If NPO: use lactulose enemas q4–6 hours
      • Hepatology consult if refractory

  • Ascites

    • Diuretics

      • Resume when hemodynamically stable
      • If starting new:
        • Spironolactone 100mg PO daily → up to 400mg
        • Furosemide 40mg PO daily → up to 160mg[^12]

    • If surgical drain present:

      • Empty every 4 hours x 72h
      • Remove ASAP after 72h if ascites controlled[^11]
      • Replace albumin: 6g of 25% albumin per liter drained
      • SBP prophylaxis if intra-abdominal sepsis covered:
        • PO: Ciprofloxacin 500mg daily
        • IV: Ceftriaxone 1g daily

    • If no drain:

      • Consider large-volume paracentesis (LVP)
        • Indications:
          • Ascites leak from surgical site
          • Suspected peritonitis
          • Diuretics contraindicated
        • Albumin: 6–8g 25% per liter if >5L removed[^11]

    • Hepatology consult if unresponsive

  • Prophylactic Anticoagulation

    • Start if platelets >50,000[^5]
    • CrCl >30: Enoxaparin 40mg SC daily
    • CrCl <30: Heparin 5,000u SC q8h

  • Fluid Management

    • Use balanced crystalloids (e.g., LR, Plasmalyte) to reduce hyperchloremia[^11]

  • Postop Medications

    • Opiates (reduced dose/frequency):

      • Oxycodone 2.5–5mg q6h
      • Hydromorphone 0.125–0.25mg IV q6h

    • Acetaminophen safe up to 2g/day[^2]:

      • 500mg q6h or 650mg TID

    • Avoid:

      • NSAIDs (renal injury)[^2]
      • Benzodiazepines (hepatic clearance)[^2]

  • SBP Prophylaxis

    • Indications:

      • Resumption of home SBP prophylaxis
      • Intraperitoneal drain in place[^13]
      • High-risk patients[^14]:
        • Prior SBP
        • Ascites protein <1.5g/L
        • Child-Pugh C
        • Renal dysfunction (Cr >1.2, BUN >25, Na <130)
        • Active GI bleed

    • Therapy:

      • PO: Ciprofloxacin 500mg q24h
      • IV: Ceftriaxone 1g q24h if NPO[^2]

E. Indications for Perioperative Hepatology Consult

  • Management of decompensated cirrhosis (e.g., refractory ascites, encephalopathy, GI bleeding)
  • TIPS evaluation for refractory ascites
  • Liver transplant evaluation (e.g., acute liver failure)
  • Long-term management of portal vein thrombosis

III. References

[^1]: Bleszynski MS, et al. World J Emerg Surg. 2018;13:32.
[^2]: Northup PG, et al. Clin Gastroenterol Hepatol. 2019;17(4):595–606.
[^3]: Kaltenbach MG, Mahmud N. Hepatol Commun. 2023;7(4).
[^4]: Northup PG, et al. Hepatology. 2021;73(1):366–413.
[^5]: Simonetto DA, et al. Am J Gastroenterol. 2020;115(1):18–40.
[^6]: De Pietri L, et al. Hepatology. 2016;63(2):566–573.
[^7]: Ziessman HA. Clin Gastroenterol Hepatol. 2010;8(2):111–116.
[^8]: Wang SY, et al. Gut Liver. 2021;15(4):517–527.
[^9]: Delis S, et al. Surg Endosc. 2010;24(2):407–412.
[^10]: Hanna K, et al. Am J Surg. 2023;226(5):668–674.
[^11]: Seshadri A, et al. Trauma Surg Acute Care Open. 2022;7(1):e000936.
[^12]: Aithal GP, et al. Gut. 2021;70(1):9–29.
[^13]: Macken L, et al. Frontline Gastroenterol. 2022;13(e1):e116–e125.
[^14]: Biggins SW, et al. Hepatology. 2021;74(2):1014–1048.

IV. Authors

  • Stefanie P. Lazow, MD
  • Michael C. Smith, MD
  • Michael Derickson, MD
  • Andrew Medvecz, MD

October 28, 2024