Elective cholecystectomy should be avoided, and required cases should be performed in experienced centers. “The gallbladder wall may appear thickened on imaging, which may lead to the erroneous diagnosis of acute cholecystitis,” the experts noted. Hence, the diagnosis “should be made only in the appropriate clinical setting, usually in the presence of biliary pain.”
Hepatic decompensation after surgery can be severe enough to merit liver transplantation. There is no agreed-on MELD score that mandates liver transplant evaluation before elective surgery, but the experts recommend doing so if the MELD score is 15 or greater or if risk of mortality within 3 months after surgery exceeds 15%.
Postoperative management of patients with cirrhosis should include aggressive measures to prevent portal hypertension. Monitor renal function closely and avoid volume depletion or overload, the experts advised. Patients should receive only short-acting benzodiazepines and lower opiate doses, administered less often, than in the general population. Avoiding constipation is vital to minimize hepatic encephalopathy, which makes oral rifaximin a better choice than lactulose. Patients should not receive NSAIDs, which can impair renal blood flow. To prevent liver toxicity, they should not be discharged on opiate/acetaminophen combinations, which they might unknowingly take along with another drug that contains acetaminophen.
The experts disclosed no external funding sources and reported having no conflicts of interest.
SOURCE: Northup PG et al. Clin Gastroenterol Hepatol. 2018 Sep 28. doi: 10.1016/j.cgh.2018.09.043.
