Anesthesia and the HepatoBiliary

System

Objectives
Hepatic Physiology
Mechanisms of Hepatocellular Injury

Acute Parenchymal Liver Disease

Assessment of Liver Function
Preoperative Considerations
Intraoperative Considerations

Objectives
Chronic Parenchymal Liver Disease
Preoperative Considerations
Intraoperative Considerations

Postoperative Liver Dysfunction

Anesthetic Considerations

Hepatic Physiology

Liver Blood Flow

25% of Cardiac output
Hepatic artery ~25% of blood flow
Portal vein ~ 75% of blood flow
Hepatic Veins empty into the inferior vena
cava
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Splanchnic Circulation Fig 17.1

Hepatic Microcirculation
Portal Axis consists of a terminal portal venule, a
hepatic arteriole and a bile ductule
Liver Acinus functional microvascular unit
Zone 1- rich in Oxygen, mitochondria
Oxidative metabolism, synthesis of glycogen

Zone 2- transition
Zone 3- lowest in Oxygen, anaerobic metabolism,
Cytochrome P-450
Biotransformation of drugs, chemicals, and toxins
Most sensitive to damage due to ischemia, hypoxia, congestion
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Microvascular Structure Fig 17.3

Regulation of Liver Blood Flow

Intrinsic Regulation
Autoregulation
Metabolic control
Hepatic Arterial Buffer Response
Decreases in portal blood flow causes increased hepatic
arterial blood flow

Extrinsic Regulation
Neural Control
Hormones
Effects of Anesthesia
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Regulation of Liver Blood Flow

Individual anesthetics
Isoflurane and Sevoflurane preserve
Hepatic blood flow
Upper Abdominal Surgery
Hepatic blood flow reduced by 60 %

Regional Subarachnoid Block of T4

Reduces 20% of Hepatic blood flow
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Functions of the Liver - I

Metabolic
Protein: Albumin major protein, Coagulation
factors except Factor VIII
Carbohydrates: Glucose homeostasis via
gluconeogenesis and glycogenolysis
Lipids: Degraded to Acetylcoenzyme, a key
molecule in synthesis of ATP, Cholesterol and
Phospholipids
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Functions of the Liver-II

Bilirubin conjugation and secretion
Bile formation
Hematologic function
Hematopoiesis 9th to 24th week gestation

Clears Fibrin Degradation Products and

Lactate
Important in shock and massive blood loss and
transfusion
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Functions of the Liver-III

Humoral function
Insulin degraded 50% in the first pass
T4 to T3 conversion
Aldosterone, estrogen, androgen, ADH all are
inactivated by the liver
Liver disease thus, results in endocrine abnormalities

Immunologic function
Kupffer cells phagocytose antigens
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Functions of the Liver-IV

Drug Biotransformation
Make drugs more polar for efficient elimination
Phase I Reaction
Cytochrome P450 system
Oxidation/reduction
Mixed Function Oxidases

Phase II Reaction
Conjugation most commonly catalyzed by
UDP-glucuronyl transferase
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Factors Affecting Hepatic Drug

Metabolism
Drugs with high extraction ratio are affected more
by changes in HBF
Propranolol, Lidocaine, Meperedine

Poorly extracted drugs are more sensitive to

intrinsic ability of the liver to eliminate a drug
Diazepam, Phenytoin, Coumadin

Anesthesia
Ketamine induces its own metabolism, therefore rapid
tolerance can occur
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Evaluation of Liver Function

Laboratory Tests:

ALT, AST, Alkaline phosphatase with 5-nucleotidase

Serum Albumin, Gamma-globulin
PT (best estimate of hepatic function)
Antinuclear Antibody
Chronic Active Hepatitis 75%

Antimitochondrial antibody
Primary biliary cirrhosis 100%

Radiologic Techniques
Cholangiography, Radionuclide and Ultra sound
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Acute Viral Hepatitis

Postpone elective surgery
High mortality and morbidity
Acute encephalopathy, avoid premed
sedatives
Frequent blood glucose monitoring for
hypoglycemia
Correction of Coagulopathy with Vit K,
FFP and platelet transfusion
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Algorithm for Abnormal

Transaminase levels fig 54-1A

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Algorithm for Abnormal

Transaminase levels fig 54-1B

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Algorithm for Abnormal

Transaminase levels fig 54-1C

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Chronic Liver Disease

or Cirrhosis PreOp
considerations
Portal hypertension may lead to GI
hemorrhage
Rx Fluid resuscitation
Must be done carefully to avoid rebleeding of
varices
Vasopressin and Octreotide constrict splanchnic
arteriolar bed
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Chronic Liver Disease PreOp

Ascites is due to portal hypertension and
sodium retention that occurs with cirrhosis
Rx with Sodium and water restriction and
diuretics
Diuretics
Cause hyponatremia and hyperkalemia
Check and correct electrolytes
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Chronic Liver Disease /PreOp

Paracentesis of Ascites
Not exceed 1 Liter/day for a daily weight loss
of 0.5 to 1.0 kg
1 liter of ascites fluid contains 10 grams of
Albumin
Each liter of ascites removed must be replaced
by 50 ml of 25% Albumin

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Chronic Liver Disease /PreOp

Hepatorenal syndrome can be precipitated
By aggressive paracentesis, potent diuretics like
Zaroxolyn
Avoid aminoglycosides (contraindicated),
NSAIDS, renal contrast, volume depletion

Hepatic Encephalopathy
Dysarthria, flapping tremor, hyperreflexia
Avoid long acting benzodiazepines, high dose
opiates and diuretics
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Chronic Liver Disease /PreOp

Child-Turcotte-Pugh Classification
Lab and clinical criteria to predict operative
survival in patients with Cirrhosis
Class C, Surgical risk of Mortality rate 50%

Serum bilirubin > 3 mg/dl

Albumin < 3 g/dl
PT > 6 sec of control
Ascites uncontrolled, encephalopathy advanced,
nutrition poor
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Chronic Liver Disease /IntraOp

Optimum drugs or techniques are unknown
Avoid or reduce dose of drugs excreted via the liver
such as Lidocaine, Meperidine, Morphine
Succinylcholine acceptable, effects are not
prolonged significantly
NDMB may have prolonged duration of action
Atracurium may be better as it is eliminated by Hoffman
elimination
Vecuronium < 0.6 mg/kg, Atracurium < 0.15 mg/kg
Avoid Pancuronium
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Chronic Liver Disease/IntraOp

Most IV induction agents are metabolized by the
liver but recovery depends on redistribution. Safe to
use Propofol, Thiopental
For Inhalational agents, Isoflurane and Sevoflurane
are better than Halothane as Hepatic Blood Flow is
decreased to a lesser degree
Fentanyl and Sufentanil single dose bolus does not
change elimination half life
Remifentanil is a safer choice as it is degraded by
tissue and RBC Esterases
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Chronic Liver Disease/IntraOp

Laparotomy with Abdominal Paracentesis of Ascites
Maintain Intravascular volume,
Rx with Albumin

Patients with GI hemorrhage

Receiving blood products may have decreased clearance
of Citrate which can lead to hypocalcemia

Bleeding diathesis
Rx with FFP or Prothrombin complex to correct PT
within 3 secs of normal
Transfuse if platelets < 100,000/uL, Rx with DDAVP
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PostOp Complications
Reversible minor changes are common
PostOp Jaundice may be due to hemolysis
of transfused blood
Shock Liver syndrome can occur if
prolonged hypotension persisted
Marked by severe hepato-cellular necrosis
SerumTransaminases levels increased > 10 fold

Bleeding, Sepsis, Renal failure

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Summary-I
Liver functions include

Protein synthesis
Drugs, fat and hormone metabolism
Immunologic function
Bilirubin formation and excretion
Glucose homeostasis

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Summary-II
For Acute Hepatitis
Postpone all elective procedures as the
mortality rate is very high

For unexpected high Transaminase levels

Repeat LFTs, if stable or decreasing may
proceed with surgery
Otherwise GI consult should be obtained
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Summary-III
In Chronic Liver disease pre-op issues
include

GI hemorrhage
Ascites, electrolyte imbalances
Hypoglycemia,
Coagulopathy and bleeding disorder

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Summary-IV
In Chronic liver disease intra-operatively
Avoid or reduce drugs that are eliminated by liver
IV inductions agents are considered safe
Inhalational agents
Use Isoflurane, avoid Halothane
Avoid Sevoflurane if risk of Hepato-Renal Syndrome

Muscle Relaxants all are acceptable

Vecuronium and Rocuronium have increased duration of
action

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Summary-V
In Chronic liver disease intra-operatively
Opioids can be used
Maintain Intravascular volume
Consider replacing 50 mL of 25% Albumin
for each liter of ascites fluid removed
Blood products can cause hypocalcemia and
Calcium need to be replaced
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Summary-VI
Post-Op Liver dysfunctions
Reversible minor changes are common
Post op Jaundice may be due to hemolysis, but
other causes should be sought
Shock Liver syndrome presented by
hepatocellular necrosis can occur due to
prolonged hypotension

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References
Anesthesia, Fifth Edition/ Ronald D. Miller, Hepatic
Physiology, Chapter 17 & Anesthesia and the
Hepatobiliary System, Chapter 54.
Anesthesia and Co-Existing Disease, Fourth Edition/
Robert K Stoelting, Stephen F. Dierdorf, Diseases of the
Liver and Biliary Tract, Chapter 18.
Clinical Anesthesia, Fourth Edition/ Paul G. Barash, et.al.,
Anesthesia and the Liver, Chapter 39

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