Special situations in surgery: the jaundiced patient

Summary

Preoperative management of the jaundiced patient

Adequate preoperative preparation is essential in the jaundiced patient. Preparation entails correction of metabolic derangement, optimizing the general condition of the patient, and specific measures that aim to reduce the incidence of complications associated with jaundice on systems such as:

1. Immune: increased risk of infections (cholangitis, septicaemia, wound infections)

2. Haematological: clotting abnormalities

3. Metabolic: electrolyte abnormality such as hypernatraemia and hypokalaemia

4. Renal: hepatorenal syndrome/acute renal failure

5. Hepatic: hepatitis, fulminant liver failure

6. CNS: delirium and hepatic encephalopathy

7. GI tract: gastrointestinal bleeding from varices

8. Endocrine: hypoglycaemia due to depletion of glycogen stores.

HISTORY

Duration of the jaundice (acute or chronic) and symptoms suggesting cause (e.g. dark urine, pale stools)

Family history of haemolytic illnesses e.g. spherocytosis, glucose-6-phosphate dehydrogenase deficiency

Drug history (many drugs including anaesthetic agents are metabolized by the liver and may therefore have a prolonged duration of action)

Detailed history of alcohol intake.

EXAMINATION

Full systematic examination

Exclude preoperative cholangitis/sepsis secondary to other causes

Exclude spontaneous bacterial peritonitis (SBP) in patients with chronic liver disease

Exclude preoperative hepatic failure (ascites, hepatic encephalopathy).

INVESTIGATIONS

FBC: exclude preoperative anaemia, and elevated WCC suggesting preoperative infection

Clotting screen: exclude prolonged prothrombin time (PT)

Urea and electrolytes: ensure normal renal function, exclude preoperative hypernatraemia and hypokalaemia

Liver Function tests: establish baseline bilirubin, transaminases and albumin

Blood glucose

Calculate the severity of chronic liver disease if present using Child's classification which helps quantify the perioperative risk (see table).