Clinical Challenges in Emergency General Surgery: Cirrhotic Patients

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.  

Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality)

·      Bilirubin, albumin, INR, ascites, encephalopathy

·      Used to predict operative mortality based on cirrhosis severity

·      Mortality in EGS:

- Child-Pugh A: 10% electively and 22% emergently

- Child-Pugh B: 30% electively and 38% emergently

- Child-Pugh C: 80% electively and up to 100% emergently

Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older)

·      creatinine, bilirubin, INR, and sodium

·      MELD < 20 – 1% increase in mortality with each point increase

·      MELD > 20 – 2% increase in mortality with each point increase

Pre-operative Planning

·      Identification of cirrhosis with physical examination, bloodwork and imaging

·      Involvement of other medical services (internal medicine, hepatology, ICU) as needed

·      Cirrhosis optimization, if possible

·      Abdominal wall mapping

Unexpected Intraoperative Finding

Ventral Hernia + Cirrhosis

·      Ideally, control ascites pre-operatively, if you can’t consider leaving drains

·      Small (< 2cm) hernias close primarily

·      Larger (>2cm) hernias repair with mesh unless infected filed (controversial)

·      Minimally invasive repairs can be performed

Benign Biliary Disease + Cirrhosis

·      Incidence of gallstones is 4-5 times higher in cirrhotic patients

·      Prophylactic laparoscopic cholecystectomy (LC) generally not done

·      LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis)

·      Cholecystostomy and ERCP are safe



References: 



Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32

Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5.

Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400.

Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855.



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