• Hepatitis C is a virus that can cause acute and chronic inflammation of the liver. Clinical presentation can range from inactive, dormant carrier states to severe fibrosis, cirrhosis, end-stage liver disease, or hepatocellular carcinoma.
• Patients with hepatitis C can present perioperatively for procedures that are related (e.g., liver transplantation, transjugular intrahepatic portosystemic shunt (TIPS), and liver resection) and unrelated to liver disease.
• Healthcare workers are at an increased risk for exposure due to needlestick injuries. The average incidence of seroconversion to hepatitis C virus (HCV) after unintentional needle sticks or sharps exposures from an HCV-positive source is 1.8% (range of 0–7%) (1).
• Unfortunately, at this time there is no proven effective postexposure prophylaxis for persons exposed to HCV blood or contaminated body fluids.

The US Centers for Disease Control and Prevention (CDC) recommend assessment of HCV risk factors; those with risk factors should be screened for HCV antibodies (anti-HCV). The American Association for the Study of Liver Diseases rates the level of evidence for screening in all of the following risk groups as class 1B (3):

• High risk: IV drug abusers, hemophilia patients treated with clotting factor concentrates produced before 1987, HIV-positive patients
• Intermediate risk: Recipients of blood transfusions or solid organ transplants before 1992, patients with unexplained elevated aminotransferase levels, patients born from infected mothers.
• Low risk: People who have had sexual relations with multiple or infected partners; healthcare workers exposed to HCV (e.g., needlestick) (4).

• HCV replicates within hepatocytes but can be found in multiple sites throughout the body. It is not directly hepatotoxic.
• Liver parenchyma damage is mediated by inflammatory cytokines that lead to varying degrees of hepatic fibrosis. Only some patients develop progressive fibrosis and eventually cirrhosis. Predictors of progression include
  • Advanced age at the time of infection
  • Male gender
  • Excessive alcohol use
  • Co-infection with hepatitis B virus (HBV)
  • Hemophiliacs with multiple transfusions
  • Injection drug users and HIV
  • Persistently elevated aminotransferase activity
  • Concomitant liver disease (5–7)
• Because the immune system's antibody response cannot clear the infection, there is slow progress in the development of a vaccine.

• Hepatitis C infection alone without end-organ damage usually does not require specific perioperative considerations. However, even asymptomatic patients should be screened before elective surgery; the INR is the most sensitive indicator of disease severity.
• Patients who have developed liver disease or cirrhosis should be carefully evaluated and optimized prior to surgery. Perioperative goals should include maintaining hepatic perfusion and avoiding factors that might precipitate liver failure or hepatic encephalopathy.
• Elective surgery should be delayed in patients with acute hepatitis of any etiology until resolution (8).

• Chronic hepatitis C infection is usually asymptomatic.
• In the acute phase, look for signs of acute hepatitis: Malaise, nausea, and right upper quadrant pain, followed by dark urine and jaundice.
• Patients with uncompensated end-stage liver dysfunction can present with signs of encephalopathy.

• Liver transplantation
• TIPS
• Large volume paracentesis
• Endoscopic variceal ligation

• Interferon-alpha and oral ribavirin during the first 6 months of infection.
• Diuretics (spironolactone) for ascites
• Antibiotics (cephalosporins) for spontaneous bacterial peritonitis
• Lactulose and poorly absorbable antibiotics (rifaximin, neomycin, metronidazole) for hepatic encephalopathy.

Cirrhosis and end-stage liver disease manifest as impaired hepatic synthesis and metabolism as well as increased hepatic vascular pressures:

• CNS: Encephalopathy, asterixis, peripheral neuropathy
• Cardiovascular: Decreased systemic vascular resistance, high output cardiac failure
• Pulmonary: Pulmonary shunting may cause hypoxemia and pulmonary hypertension; pleural effusions
• Hepatic: Cirrhosis, portal hypertension, varices, ascites, splenomegaly
• Renal: Insufficiency or failure; hepatorenal syndrome describes renal disease in the absence of primary disease and may be related to hypoperfusion.
• Coagulation: Decreased production of hepatic synthesized factors, thrombocytopenia
• Infectious: Spontaneous bacterial peritonitis
• Cutaneous: Jaundice, palmar erythema, spider nevi, male gynecomastia

• Elective surgery should be delayed in patients with acute hepatitis of any etiology until resolution of hepatocellular dysfunction (1).
• When surgery cannot be avoided, meticulous care should be taken perioperatively to maintain hepatic perfusion and avoid factors that might precipitate liver failure, hepatic encephalopathy, or both.

• Acute infection
  • Symptoms consistent with acute viral hepatitis along with jaundice/dark urine or serum alanine aminotransferase levels >400 IU/L
  • Positive hepatitis C antibody (anti-HCV), recombinant immunoblot assay (HCV RIBA), or nucleic acid test (NAT).
  • Combined with a negative IgM antibody to hepatitis A virus and hepatitis B core antigen
• Chronic infection
  • Symptoms may range from none to severe
  • Positive anti-HCV by EIA combined with either a more specific assay or HCV RIBA, or NAT.

• Depends on extent of liver disease, surgical procedure, and intraoperative course.
• Monitor for signs of acute liver failure, including worsening jaundice, encephalopathy, and ascites.

• Patients with preoperative acute hepatitis or cirrhosis from hepatitis C are at increased risk of postoperative jaundice.
• Patients with more advanced liver disease (CTP class B or C cirrhosis) are at increased risk of encephalopathy, cerebral edema, coagulopathy, hemorrhage, and portal hypertension.

• Infectious exposure to the hepatitis C patient
  • Cuts or needle-stick injuries may occur in up to 15% of all surgeries.
  • The risk of HCV transmission depends on the volume of blood transmitted, but <0.5% of such injuries are considered high risk (e.g., hollow-bore needle) (9).
  • There is no vaccine or immunoglobulin to protect against transmission. Additionally, prophylactic post-exposure treatment with interferon and/or ribavirin is not recommended.
  • At this time, the following recommendations are:
    • Baseline testing of the injured for anti-HCV and ALT activity
    • Follow-up testing 4–6 months for anti-HCV and ALT activity or HCV RNA at 4–6 weeks
    • Careful monitoring for laboratory abnormalities and signs/symptoms of acute infection
    • Avoidance of blood, plasma, organ, tissue, or semen donation

• Liver Resection
• Liver Transplant
• Transjugular Intrahepatic Portosystemic Shunt (Tips)
• Cirrhosis
• End-Stage Liver Disease
• Postoperative Jaundice
• Hepatic Encephalopathy
• Infectious Disease Exposure in the Healthcare Worker

• 070.51 Acute hepatitis C without mention of hepatic coma
• 070.54 Chronic hepatitis C without mention of hepatic coma
• 070.70 Unspecified viral hepatitis C without hepatic coma

• B17.10 Acute hepatitis C without hepatic coma
• B18.2 Chronic viral hepatitis C
• B19.20 Unspecified viral hepatitis C without hepatic coma

Neesa Patel , MD