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 Cirrhosis Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Cirrhosis is characterized by regenerative nodules surrounded by dense... read more 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 Acute Liver Failure Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. Treatment is mainly supportive... read more in a patient with viral or alcoholic hepatitis Causes of Hepatitis Hepatitis is an inflammation of the liver characterized by diffuse or patchy necrosis. Hepatitis may be acute or chronic (usually defined as lasting > 6 months). Most cases of acute viral hepatitis... read more .
(See also Liver Structure and Function Liver Structure and Function The liver is a metabolically complex organ. Hepatocytes (liver parenchymal cells) perform the liver’s metabolic functions: Formation and excretion of bile as a component of bilirubin metabolism... read more and Evaluation of the Patient with a Liver Disorder Evaluation of the Patient With a Liver Disorder History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders. Various symptoms may develop, but few are... read more .)
Diagnosis of postoperative jaundice requires liver tests Laboratory Tests of the Liver and Gallbladder Laboratory tests are generally effective for the following: Detecting hepatic dysfunction Assessing the severity of liver injury Monitoring the course of liver diseases and the response to treatment... read more . Timing of symptoms also aids in diagnosis.
Multifactorial mixed hyperbilirubinemia is the most common reason for postoperative jaundice Jaundice Jaundice is a yellowish discoloration of the skin and mucous membranes caused by hyperbilirubinemia. Jaundice becomes visible when the bilirubin level is about 2 to 3 mg/dL (34 to 51 micromol/L)... read more . It is caused by increased formation of bilirubin Overview of bilirubin metabolism The liver is a metabolically complex organ. Hepatocytes (liver parenchymal cells) perform the liver’s metabolic functions: Formation and excretion of bile as a component of bilirubin metabolism... read more 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” Ischemic Hepatitis Ischemic hepatitis is diffuse liver damage due to an inadequate blood or oxygen supply. (See also Overview of Vascular Disorders of the Liver.) Causes are most often systemic: Impaired hepatic... read more results from insufficient liver perfusion, not inflammation. The cause is transient perioperative hypotension or hypoxia. Typically, aminotransferase levels increase rapidly (often > 1000 units/L [16.7 microkat/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 weeks, 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 Hepatitis C, Chronic Hepatitis C is a common cause of chronic hepatitis. It is often asymptomatic until manifestations of chronic liver disease occur. Diagnosis is confirmed by finding positive anti-HCV and positive... read more 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.