Anaesthetic Management of Obstructive Jaundice

Pathophysiology Relevant to Anaesthesia

Preoperative Assessment & Optimisation

History & Examination

• Symptoms: pruritus, dark urine, pale stools, right upper quadrant pain, fatigue, weight loss
• Assess for jaundice, hepatomegaly, ascites, pleural effusions, peripheral oedema, encephalopathy, bruising

Investigations

Risk Stratification

• Child–Turcotte–Pugh (CTP) score — uses bilirubin, albumin, PT, ascites severity, encephalopathy
• MELD score ≥ 15 (serum bilirubin, INR, creatinine) indicates significantly elevated perioperative mortality
• PT prolongation ≥3 seconds unresponsive to vitamin K signals synthetic failure, not just cholestasis

Optimisation Steps

• Cause: vitamin K malabsorption (requires bile salts), factor synthesis failure, thrombocytopenia from splenomegaly
• Vitamin K 1–5 mg orally or subcutaneously daily for 1–3 days corrects cholestasis-related coagulopathy
• FFP transfusion targeting INR <1.5 if synthetic failure is present
• Platelets if thrombocytopenic — Miller's Anesthesia, 10e

• Conjugated bilirubin >8 mg/dL → portal endotoxaemia → intense renal vasoconstriction → AKI in up to 2/3 of patients undergoing major biliary surgery
• Oral bile salts preoperatively help reduce endotoxin absorption
• IV mannitol preoperatively or intraoperatively helps maintain renal tubular flow
• Lactulose 30 mL orally every 6 hours for 3 days preoperatively (last dose within 12 hours of surgery) — reduces endotoxaemia by acidifying gut contents
• Maintain urinary output ≥0.5 mL/kg/hr — Barash, Clinical Anesthesia, 9e; Miller's Anesthesia, 10e

• Sodium restriction, spironolactone, paracentesis (analyse fluid for SBP)
• Reduces risk of wound dehiscence and improves diaphragmatic excursion and pulmonary function

• Identify and treat precipitants: infection, GI bleeding, hypovolaemia, sedative drugs
• Lactulose is first-line therapy
• Avoid sedatives and opioids where possible

• Preoperative biliary drainage (ERCP stenting or percutaneous transhepatic drainage) is considered in severe hyperbilirubinaemia (bilirubin >10 mg/dL), significant renal dysfunction, or marked pruritus, though evidence for routine use is mixed — Yamada's Textbook of Gastroenterology, 7e

• Cirrhosis and obstructive jaundice are associated with malnutrition and sarcopenia; enteral/parenteral supplementation may have perioperative benefit

Intraoperative Management

Monitoring

• Standard monitoring (SpO₂, ETCO₂, NIBP, ECG, temperature)
• Invasive arterial line — for beat-to-beat BP monitoring, frequent ABGs; obstructive jaundice cases often involve haemodynamic instability
• Central venous access if major fluid shifts anticipated
• Urine output — catheterise all patients; target ≥0.5 mL/kg/hr throughout

Premedication

• Sedative premedication should be used cautiously or avoided in patients with encephalopathy or severe hepatic dysfunction — prolonged action due to reduced hepatic clearance
• Benzodiazepines undergo hepatic metabolism and may precipitate or worsen encephalopathy

Anaesthetic Induction & Airway

• RSI with cricoid pressure may be warranted if ascites/delayed gastric emptying increases aspiration risk
• Avoid agents with significant hepatotoxic potential in the context of already-compromised liver

Choice of Anaesthetic Agents

Fluid Management

• Generous IV crystalloid to maintain intravascular volume and renal perfusion
• IV mannitol (e.g. 0.5 g/kg) given perioperatively helps maintain urine output and reduce renal tubular damage
• Blood products guided by coagulation monitoring (thromboelastography/ROTEM helpful in hepatic disease)
• Avoid saline-heavy regimens (hyperchloraemic acidosis worsens coagulopathy)

Haemodynamic Goals

• Maintain adequate MAP and hepatic perfusion pressure
• Abdominal surgery significantly reduces hepatic blood flow; abdominal traction elevates prostaglandins — use gentle surgical technique and avoid prolonged high IAP
• In cirrhosis/severe disease: high cardiac output + low SVR state; vasopressors (noradrenaline) may be needed if refractory hypotension develops

Glucose Monitoring

• Impaired hepatic glycogen synthesis → risk of intraoperative hypoglycaemia
• Hourly blood glucose monitoring recommended; maintain normoglycaemia with glucose supplementation

Postoperative Management

• Continued renal vigilance: AKI most commonly manifests in the first 48–72 hours postoperatively; maintain urine output, avoid nephrotoxins, continue bile salts/lactulose
• Coagulation: recheck INR and haematology; supplement vitamin K, FFP, or platelets as needed
• Analgesia: use multimodal analgesia; regional techniques (epidural, wound infiltration) preferred to minimise opioid load; neuraxial techniques require careful assessment of coagulation
• Encephalopathy monitoring: assess for emergence/worsening; minimise opioids and benzodiazepines
• Liver function monitoring: serial LFTs; identify and treat any postoperative liver dysfunction early (Table 46-10 causes include drugs, anaesthetics, ischaemia, sepsis, bile duct injury)
• Infection surveillance: impaired Kupffer cell function in obstructive jaundice reduces immune clearance; prophylactic antibiotics and wound care are important
• Critical care referral: Child–Pugh C patients undergoing major procedures should be managed in a high-dependency or intensive care unit

Summary Table: Key Anaesthetic Priorities