Emergency Surgery for Acute Cholecystitis: Navigating High Liver Enzymes

The emergency physician arranged for an urgent surgical operation?

Hello Dr.
Chen,
I would like to inquire about the following narrative:
A patient presented to the emergency department late at night with abdominal pain.
Blood tests revealed elevated liver enzymes, and a CT scan was performed.
The diagnosis was acute cholecystitis with biliary obstruction.
The patient was treated with antibiotics and analgesics for symptom relief and was discharged home before dawn.
The night shift emergency physician advised the patient to refrain from eating and drinking, with plans to return for an emergency surgery after the day shift.

While waiting in the emergency department, the mid-shift emergency physician repeatedly asked about the patient's alcohol consumption (which was negative) and communicated the abnormal liver enzyme levels to the surgical team.
The patient was advised to undergo outpatient testing and surgery arrangements.

Question 1: Is there a protocol that prevents surgery if liver enzymes are elevated?
Question 2: Given the elevated liver enzymes, is there a suspicion of other underlying conditions that necessitate further testing before proceeding with cholecystectomy?
Question 3: Are the tests conducted in the emergency department different from those in outpatient settings, and does the elevated liver enzyme level negate the night shift emergency physician's surgical arrangements?
Question 4: How do differing medical cultures and perspectives among physicians in various hospitals affect treatment approaches?
Thank you.

Chuanqi, 40~49 year old female. Ask Date: 2024/06/09

Dr. Chen Shidian reply Gastroenterology and Hepatology

If the liver function tests are significantly elevated, anesthesia or surgery may not be advisable.
Please discuss the details with your attending physician.

Reply Date: 2024/06/09

More Info

Emergency surgery for acute cholecystitis can be a complex decision, especially when elevated liver enzymes are involved. In your case, the situation is compounded by the need to balance the urgency of treating acute cholecystitis against the potential risks posed by high liver enzyme levels.

Understanding the Risks
1. High Liver Enzymes and Surgical Risks: Elevated liver enzymes (such as AST and ALT) can indicate liver dysfunction or damage, which may increase the risk of complications during surgery. High liver enzyme levels can suggest underlying liver disease, which may affect the patient’s ability to metabolize anesthesia and recover post-operatively. Generally, if liver enzymes are significantly elevated, many surgeons may prefer to delay elective surgery until the liver function is stabilized. This is particularly true if the patient exhibits signs of liver failure or if there are other concerning laboratory findings.

2. Potential for Other Pathologies: When liver enzymes are elevated, it raises the suspicion of additional underlying conditions such as hepatitis, biliary obstruction, or even liver cirrhosis. In such cases, further diagnostic imaging or laboratory tests may be warranted to rule out other serious conditions before proceeding with surgery. This cautious approach helps ensure that the surgical team is fully aware of the patient’s health status and can plan accordingly.

Surgical Decision-Making
1. Emergency vs. Elective Surgery: In cases of acute cholecystitis, especially when there is a risk of complications such as perforation or sepsis, surgery is often indicated. However, the timing of the surgery can vary based on the patient’s overall health and laboratory findings. If the patient is stable and the risk of complications from delaying surgery is high, the surgical team may decide to proceed despite elevated liver enzymes, but with careful monitoring and preparation.

2. Consultation with Specialists: It is essential for the surgical team to collaborate closely with gastroenterologists or hepatologists when faced with elevated liver enzymes. This multidisciplinary approach can provide insights into the best course of action, including whether to proceed with surgery or to manage the condition medically first.

3. Cultural and Institutional Variability: Different hospitals and medical teams may have varying protocols and philosophies regarding the management of acute cholecystitis with elevated liver enzymes. Some may adopt a more conservative approach, while others may be more aggressive in surgical intervention. It is crucial for patients and their families to communicate openly with their healthcare providers about their concerns and to seek clarification on the rationale behind the proposed treatment plan.

Conclusion
In summary, while elevated liver enzymes can complicate the management of acute cholecystitis, they do not automatically preclude surgical intervention. The decision to proceed with surgery should be based on a comprehensive assessment of the patient’s overall health, the severity of the cholecystitis, and the potential risks involved. Continuous communication between the patient, surgical team, and any consulting specialists is vital to ensure the best possible outcome. If there are significant concerns about liver function, it may be prudent to consider additional testing or even a temporary delay in surgery to optimize the patient’s condition before proceeding.

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