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Postoperative Liver Dysfunction
Mild liver dysfunction sometimes occurs after major surgery even in the absence of preexisting liver disorders. This dysfunction usually results from hepatic ischemia or poorly understood effects of anesthesia. Patients with preexisting well-compensated liver disease (eg, cirrhosis with normal liver function) usually tolerate surgery well. However, surgery can increase the severity of some preexisting liver disorders; eg, laparotomy may precipitate acute liver failure in a patient with viral or alcoholic hepatitis.
Diagnosis of postoperative jaundice requires liver function tests. Timing of symptoms also aids in diagnosis.
Multifactorial mixed hyperbilirubinemia is the most common reason for postoperative jaundice. It is caused by increased formation of bilirubin and decreased hepatic clearance. This disorder most often occurs after major surgery or trauma requiring multiple transfusions. Hemolysis, sepsis, resorption of hematomas, and blood transfusions can increase the bilirubin load; simultaneously, hypoxemia, hepatic ischemia, and other poorly understood factors impair hepatic function. This condition is usually maximal within a few days of operation. Hepatic insufficiency is rare, and hyperbilirubinemia typically resolves slowly but completely. Liver laboratory tests can often differentiate multifactorial mixed hyperbilirubinemia from hepatitis. In multifactorial mixed hyperbilirubinemia, severe hyperbilirubinemia with mild aminotransferase and alkaline phosphatase elevations are common. In hepatitis, aminotransferase levels are usually very high.
Ischemic postoperative “hepatitis” results from insufficient liver perfusion, not inflammation. The cause is transient perioperative hypotension or hypoxia. Typically, aminotransferase levels increase rapidly (often > 1000 units/L), but bilirubin is only mildly elevated. Ischemic hepatitis is usually maximal within a few days of the operation and resolves within a few days.
Halothane-related hepatitis can result from use of anesthetics containing halothane or related agents. It usually develops within 2 wk, is often preceded by fever, and is sometimes accompanied by a rash and eosinophilia.
True postoperative hepatitis is now rare. It used to result mainly from transmission of hepatitis C virus during blood transfusion.
The most common cause of postoperative cholestasis is extrahepatic biliary obstruction due to intra-abdominal complications or drugs given postoperatively. Intrahepatic cholestasis occasionally develops after major surgery, especially after abdominal or cardiovascular procedures (benign postoperative intrahepatic cholestasis). The pathogenesis is unknown, but the condition usually resolves slowly and spontaneously. Occasionally, postoperative cholestasis results from acute acalculous cholecystitis or pancreatitis.
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