Preoperative assessment and risk stratification in a patient of cirrhosis of liver

Preoperative assessment
Clinical History

1. History of weight loss,malaise,dyspepsia,jaundice,heavy alcohol intake,hematemesis,easy bruising,pedal edema,dyspnoea,easy fatigue,
2. Previous surgeries and its association with jaundice,drug intake(acetaminophen,rifampicin,phenytoin,),blood transfusion,
3. Physical examination: Palmar erythema, Dupytrens contracture,spider naevi,peripheral edema, bruising,gynaecomastia muscle wasting,glossitis,hepatomegaly,parotid swelling,encephalopathy,features of portal hypertension like ascitis,spenomegaly and caput medusae.
4. Investigations: A full blood count to detect anemia,thrombocytopenia,Prothrombin time is a indicator of hepatocellular function,Base line renal function,Liver function test,Electrocardiography and echocardiography if risk factors of left ventricular dysfunction,cardiomyopathy,Chest radiography and lung fuction test to deliniate any restrictive or obstructive pulmonary disease

Risk Stratification

Preoperative evaluation of patients with liver disease should focus on extent of liver dysfunction and effect on other organ 

Viral hepatitis is a risk to theatre personnel and patients should be screened for Hepatitis B and C

Modified Child-Turcotte-Pugh Scoring System

Parameters	Modified Child-Turcotte-Pugh Score *
	1	2	3
Albumin (g/dL)	>3.5	1.8-3.5	<2.8
Prothrombin time
Seconds prolonged	<4	4-6	>6
International normalized ratio	<1.7	1.7-2.3	>2.3
Bilirubin (mg/dL) †	<2	2-3	>3
Ascites	Absent	Slight-moderate	Tense
Encephalopathy	None	Grade I-II	Grade III-IV

Points are added to make a total scoring -score of 5-6 is considerd Child's class A and is associated with low operative mortality risk(>5%) , a Score of 7-9 is Child's class B and is associated with moderate risk(25%) and a total score of 10-15 is Child's class C and carries high risk (>50%)

Other indicators of poor prognosis include malnutrition,emergency surgery,sepsis and blood loss.

Predicting perioperative risk of cirrhosis and other forms of acute and chronic liver disease is enhanced by the incorporation of the Model for End-stage Liver Disease (MELD) score Although the MELD score was introduced as a tool to better prioritize organ allocation for orthotopic liver transplantation, studies suggest the superiority of MELD to CPT in predicting both intermediate and long-term survival for patients with cirrhosis, acute alcoholic hepatitis, and other forms of chronic liver disease.MELD score is based on patients serum bilirubin,creatinine and international normalised ratio(INR) for prothrombin time and is calculated with a validated predictive equation (3.8x ln bilirubin value)+(11.2x ln INR) +(9.6xln creatinine value,where ln is the natutal logarithm. The maximum MELD score is 40 ,a MELD score of at least 8 predicts good outcome after TIPS and > 18 predicts poor outcome but since its implementation  MELD is expanded to predict mortality and morbidity in other procedures

other scoring systems to evaluate are Glasgow coma score if patient has hepatic encephalopathy