• Jaundice in the postoperative period may result from a combination of hypotension, hypoxemia, pigment overload, or sepsis, with the clinical picture resembling hepatitis. It is:
  • Usually evident within 2 weeks after surgery
  • Can occur in up to 47% of patients with cirrhosis
  • Unusual in patients without liver disease
• Abnormal liver chemistry tests (LCTs), on the other hand, can range from 25–75% in patients without liver disease; mild elevations are thus considered typical.
• Postoperative LCT abnormalities and jaundice are usually categorized and worked-up in one of the following 4 groups:
  • Increased bilirubin production (pre-hepatic)
  • Hepatocellular disease (intrahepatic)
  • Cholestatic disorders (posthepatic)
  • Pre-existing liver disease

• Pre-existing liver disease: Viral hepatitis, cirrhosis, alcoholic hepatitis, mononucleosis, or congenital disorders
• Major blood loss requiring blood transfusions
• Prolonged hypotension in surgery
• Medications: Erythromycin, chlorpromazine, halothane, enflurane, sulfonamides, penicillin, phenytoin, methyldopa, acetaminophen, methyltestosterone, rifampin, isoniazid, and nitrofurantoin
• Hemolytic blood diseases: Sickle cell, thalassemias, G6PD deficiency, autoimmune anemia
• Mechanical heart valves
• In cardiac surgery: Prolonged bypass, aortic cross clamping; intra-aortic balloon pump use; pre-operative hepatic dysfunction due to heart failure; and type of surgery
• Total parenteral nutrition (TPN): Short-term use can cause fatty liver and cholestasis, whereas long-term use can result in steatohepatitis, cholestasis, and acalculous cholecystitis
• Acalculous cholecystitis: Male; major surgery including cardiac and GI, trauma, burns, renal failure; mechanical ventilation with positive end expiratory pressure (PEEP); TPN for at least 3 months; and critically ill patients

• Heme is a prosthetic group with an iron atom in the center of a porphyrin group. It is most commonly found in hemoglobin molecules within red blood cells.
  • Normal breakdown of hemoglobin occurs in reticuloendothelial cells with unconjugated (indirect) bilirubin byproduct.
  • Unconjugated bilirubin is water insoluble, binds readily to albumin, and is conjugated with glucuronic acid in the liver.
  • Conjugated (direct) bilirubin is water soluble and excreted in bile and urine.
  • Normal lab values:
    • Total bilirubin: 0.2–1.9 mg/dL
    • Direct bilirubin: 0–0.3 mg/dL
    • Indirect bilirubin: 0.2–0.7 mg/dL
• Jaundice is the clinical manifestation of hyperbilirubinemia and describes a yellow pigmentation of the skin, sclera, and mucus membranes.
• Pre-hepatic causes of postoperative jaundice result from increased red blood cell breakdown and unconjugated bilirubin levels. This can overwhelm the liver's capacity to conjugate bilirubin. Perioperatively, this can result from:
  • Hemolysis (the rupture and release of hemoglobin) can result from blood transfusions, hemolytic diseases, mechanical heart valves, cardiac surgery.
  • Hematoma resorption
• Intrahepatic causes of postoperative jaundice result in a reduced ability to conjugate bilirubin. Perioperative causes include hepatocellular injury (ischemia, medications, viral) or pre-existing liver disease.
  • Ischemic injury may result from cardiogenic or noncardiogenic shock, hypoxemia, or surgical injury (hepatic artery ligation, post-liver transplant)
  • Medications, TPN, and volatile agents
  • Viral infections can present after 3 weeks of surgery. In 2001, the Centers for Disease Control and Prevention reported the risk of hepatitis C infection from a unit of transfused blood in the US to be less than one per million transfused units.
  • Pre-existing liver disease that was not recognized until after surgery is also possible. for example, unrecognized cholestatic liver disease such as primary sclerosing cholangitis or primary biliary cirrhosis. Gilbert's syndrome, which is the most common inherited cause of unconjugated hyperbilirubinemia, is another possibility.
• Posthepatic causes of postoperative jaundice result from an inability to excrete conjugated bilirubin. Intrahepatic and extrahepatic causes can result in the obstruction of bile flow or cholestasis.
  • Intrahepatic cholestasis can be caused by benign postoperative cholestasis, acalculous cholecystitis, sepsis, or medication induced.
  • Extrahepatic cholestasis can be caused by choledocholithiasis, cholecystitis, acalculous cholecystitis, upper abdominal surgery, postoperative pancreatitis, postoperative bile duct injury, stricture or tumor, or unrecognized liver diseases like primary sclerotizing cholangitis.
• Postoperative abnormal LCTs in normal individuals may be due to decreased hepatic blood flow or the surgical procedure.

• Do not perform elective surgery in cirrhotic or acute viral hepatitis patients (5) [B].
• Avoid TPN or blood transfusions when possible.
• Avoid halothane.
• Avoid using same syringes or multidose vials on patients to prevent infectious disease spread such as hepatitis.
• Avoid severe hypotension.

• Halothane hepatitis: 38 claims
  • Halothane plus patient with underlying condition: 2 claims
  • Halothane plus a hepatotoxic chemo: 1 claim
  • Of all 41 cases, 3 occurred after 1990, most recent was 1997
  • 20 patients (49%) with halothane hepatitis died
• Infectious hepatitis: 2 claims
  • Hepatitis B from reusing syringes for skin wheel
  • Hepatitis C from reusing multidose vial (at least 41 patients in the claim)

• Cholecystectomy
• Blood Transfusions

• 782.4 Jaundice, unspecified, not of newborn
• 997.49 Other digestive system complications

• K91.89 Oth postprocedural complications and disorders of dgstv sys
• R17 Unspecified jaundice

Catherine Dawson Tobin , MD

William David Stoll , MD