Sudden Progression to Liver Failure in a Stable Cirrhotic Patient

Abstract

Purpose: Patients with cirrhosis are at risk for hepatic decompensation in case of superimposed acute liver damage. Surgical procedures in cirrhotics can also precipitate hepatic decompensation. We present a case of a stable cirrhotic patient who developed hepatic failure after acquiring acute hepatitis A (HAV) infection, and undergoing surgical procedures. Methods: A clinical vignette case report is presented. Results: A 54 year old male with no known liver disease presented with right upper quadrant pain. Laboratory data showed only a mild increase in his transaminases. Right upper quadrant ultrasound showed gallstones. He underwent an uneventful laporascopic cholecystectomy without mention of liver morphology. He presented eight days later with jaundice, malaise, lethargy, and ascites. Laboratory tests revealed bilirubin of 18.8 mg/dl, INR of 1.7, and creatinine of 4.2. No viral serologies were obtained. Imaging studies were inconclusive and the patient underwent exploratory laparotomy for possible retained biliary stone or iatrogenic bile duct damage. Operative findings included a grossly cirrhotic liver, but no biliary obstruction. Biopsy revealed micronodular cirrhosis with extensive acute necrosis. The patient was transferred for liver transplant evaluation. The patient had recently traveled to the Caribbean and his wife had contracted acute HAV infection. Serology confirmed acute HAV infection in our patient. Despite supportive care he did not improve, and subsequently underwent successful liver transplantation. Conclusion: This case illustrates several important points relating to the care of cirrhotic patients. First, acute HAV infection can have devastating effects in a cirrhotic patient. The overall case-fatality rate of acute HAV is 0.01% to 0.3%, but can reach up to 11.6% in patients with underlying chronic liver disease. Fulminant hepatic failure secondary to superinfection with HAV has been well-documented in patients with cirrhosis and chronic viral hepatitis. The CDC recommends widespread vaccination for HAV in patients with known chronic liver disease. Second, cirrhotic patients undergoing emergent intra-abdominal surgery have a high risk of morbidity and mortality. Prior data has shown peri-operative mortalities in the 10%, 30%, and 70% range for patients with Child's A, B, and C cirrhosis, respectively. Finally, there can be significant mortality (approximately 10%) in any patient undergoing surgery in the face of acute viral hepatitis. In conclusion, patients with chronic liver disease should be vaccinated against hepatitis A and B. Also, clinicians should recognize the high risk of morbidity and mortality in cirrhotic patients and patients with acute viral hepatitis undergoing surgical procedures.