Chronic Hepatitis Chronic hepatitis is a group of disorders characterized by inﬂammation of the liver for at least 6 months. The disease is divided by morphologic and clinical criteria into chronic persistent hepatitis and chronic active hepatitis. A liver biopsy is usually required to establish the extent and type of injury. The surgical risk in these patients correlates most closely with the severity of disease. The risk of surgery in patients with asymptomatic or mild disease is minimal in contrast to a significant risk for those patients who have symptomatic chronic active hepatitis (278). Elective surgery is contraindicated in symptomatic patients, and nonelective surgery is associated with significant morbidity (277). In the nonelective situation, patients taking long-term glucocorticoid therapy should be given appropriate stress coverage with a higher dose of glucocorticoids during the perioperative period. Preoperatively, patients who are not taking steroids should receive prednisone and azathioprine, which are shown to reduce the perioperative risk of complications and may result in remission in as many as 80% of patients (279). Asymptomatic carriers of the hepatitis B virus (HBV; individuals who test positive for the HBV surface antigen) are not at increased risk for postoperative complications in the absence of elevated aminotransferase levels and liver inﬂammation. There is a significant risk to the health care professional operating on these individuals. In cases of needlestick in which the patient’s hepatitis status is unknown, both the health care worker and the patient should be tested for hepatitis C virus (HCV) antibody and HBV serologic markers. If markers for HBV infection are present, hepatitis B immune globulin should be administered to unvaccinated medical personnel. A vaccination series should be initiated during the early postoperative period. If the health care worker is immune (surface antibody positive), no treatment is necessary (269). All medical personnel, and especially those in the surgical subspecialties, should receive a full course of recombinant hepatitis B vaccine as recommended by the CDC (280). Treatment for chronic hepatitis B in the 1990s centered around interferon-α with data in the 2000s showing increased benefit from the use of nucleoside analogues, including lamivudine and tenofovir (281,282). Pegylated interferon and ribavirin are used in the standard treatment of HCV (283). Consideration should be given to using these medications for patients in whom surgery cannot be avoided but is not emergent.
Alcoholic Liver Disease Alcoholic liver disease encompasses a spectrum of diseases including fatty liver, acute alcoholic hepatitis, and cirrhosis. Elective surgery is not contraindicated in patients with fatty liver because liver function is preserved. If nutritional deficiencies are discovered, they should be corrected before elective surgery. Acute alcoholic hepatitis is characterized on biopsy by hepatocyte edema, polymorphonuclear leukocyte infiltration, necrosis, and the presence of Mallory bodies. Elective surgery in these patients is contraindicated (284). Abstinence from alcohol for approximately 6 to 12 weeks along with clinical resolution of the biochemical abnormalities are recommended before surgery is considered. Severe alcoholic hepatitis may persist for several months despite abstinence and, if any question of continued activity exists, a liver biopsy should be repeated (285). In cases of urgent or emergent surgery on patients with alcohol dependence, administration of tapered doses of benzodiazepine is appropriate as prophylaxis against alcohol withdrawal.