Friedman listed several risk factors associated with perioperative morbidity and mortality in patients with cirrhosis. The author is from Massachusetts General Hospital.

Type of surgery:

(1) hepatic resection

(2) abdominal surgery, especially colectomy, gastric resection, or cholecystectomy

(3) cardiac surgery


Manner of surgery:

(1) emergent


Severity of cirrhosis:

(1) Child's class (risk C > B; risk B > A)

(2) ascites

(3) encephalopathy

(4) jaundice

(5) portal hypertension

(6) abnormal quantitative liver function tests (aminopyrine breath test, etc.)


Presence of concurrent manifestations:

(1) serious infection (pneumonia, sepsis, etc.)

(2) anemia

(3) malnutrition

(4) hypoalbuminemia

(5) hypoxemia

(6) coagulopathy (prothrombin time > upper limit of reference range + 2.5 seconds after vitamin K administration)



• I would also imagine any prolonged surgery or surgery with hypotension would increase risk. Patients with cirrhosis are prone to infarct the regenerative nodules if they become hypotensive, with the risk for acute hepatic failure.

• Several of these findings are contraindications for elective surgery (above). Additional risk factors listed as contraindications but not shown in the table above are (a) renal failure, (b) thrombocytopenia and (c) heart failure or cardiomyopathy.

• The Child-Pugh classification is based on bilirubin, serum albumin, prothrombin time, encephalopathy and ascites. All of these findings are listed separately in the list. Therefore I will not additional points in the implementation for the Child class.

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