Postoperative Jaundice

 

🔷 Definition:

Postoperative jaundice is a condition characterized by yellowish discoloration of skin and sclera due to elevated serum bilirubin levels, occurring after surgery in the absence of pre-existing liver disease.

 

🔷 Types of Hyperbilirubinemia:

  • Unconjugated (indirect): Overproduction or impaired conjugation
  • Conjugated (direct): Hepatocellular or cholestatic dysfunction

 

🔷 Incidence:

  • Common after major surgeries, especially cardiac, abdominal, orthopedic, and prolonged surgeries.
  • Can be benign and self-limiting or indicate serious pathology.

 

🔷 Classification Based on Timing:

Timing

Likely Cause

<24 hrs

Hemolysis, transfusion reaction

2–5 days

Ischemic hepatitis, drug-induced, resorption of hematomas

>5 days

Sepsis, biliary obstruction, cholestasis, viral hepatitis

 

 

🔷 Etiology

1. Prehepatic (Hemolytic) Causes:

  • Massive blood transfusion (stored RBC hemolysis)
  • Hemolytic reaction (ABO incompatibility)
  • Hematoma resorption (e.g., post orthopedic or neurosurgery)
  • Sickle cell crisis or hereditary hemolytic diseases
  • Cardiopulmonary bypass (mechanical hemolysis)

➤ Presents with isolated rise in unconjugated bilirubin, normal ALT/AST.

 

2. Hepatocellular Causes:

  • Ischemic hepatitis (“shock liver”)
    • Due to intraoperative hypotension or hypoxia
    • Sudden, massive transaminase elevation (AST/ALT > 1000 IU/L)
    • Mild bilirubin rise; resolves in days
  • Sepsis-related cholestasis
    • Occurs due to inflammatory cytokines and endotoxins
    • Common in ICU patients
  • Drug-induced liver injury (DILI)
    • E.g., paracetamol, antibiotics (ceftriaxone, erythromycin), halothane
  • Viral hepatitis
    • HBV, HCV (especially in transfusion recipients)
  • TPN-induced cholestasis
    • Especially with long-term use in ICU

➤ Mixed bilirubin rise, elevated ALT/AST, ↑ INR in severe cases

 

3. Post-hepatic (Obstructive) Causes:

  • Bile duct injury or obstruction
    • Post-cholecystectomy bile leak or stone migration
  • External compression from hematoma or drain
  • Surgical anastomotic leak or stricture

➤ Marked direct (conjugated) hyperbilirubinemia, ↑ ALP, ↑ GGT

 

4. Functional/Postoperative Cholestasis:

  • Benign, self-limiting
  • Due to cytokine-mediated impaired bile flow
  • Seen after prolonged surgery, trauma, or sepsis

 

🔷 Risk Factors

  • Major surgeries (cardiac, vascular, hepatobiliary)
  • Blood transfusions
  • Sepsis or prolonged ICU stay
  • Intraoperative hypotension or hypoxia
  • Pre-existing liver disease
  • TPN use

 

🔷 Clinical Features

  • Jaundice (usually mild)
  • Fatigue, malaise
  • Hepatomegaly in some cases
  • May be asymptomatic (incidentally noted on labs)

 

🔷 Investigations

Test

Purpose

LFTs

Determine pattern: hepatocellular vs cholestatic

CBC & Reticulocyte count

Hemolysis

LDH & Haptoglobin

Hemolysis markers

PT/INR

Hepatic synthetic function

Ultrasound abdomen

Biliary obstruction, hematoma, ascites

Viral serologies

Rule out HBV, HCV

CT or MRCP

Suspected biliary obstruction or surgical complications

 

 

🔷 Management

A. Supportive Measures

  • Hydration
  • Avoid hepatotoxic drugs
  • Nutritional support

B. Specific Treatment Based on Cause

Cause

Treatment

Hemolysis

Stop transfusion, supportive care

Ischemic hepatitis

Hemodynamic optimization

Sepsis

Source control, antibiotics

Drug-induced

Withdraw offending agent

Obstruction

ERCP or surgical re-exploration

 

 

🔷 Prognosis

  • Benign functional jaundice resolves in days
  • Ischemic or sepsis-related jaundice carries higher morbidity
  • Biliary obstruction requires prompt intervention

 

🔷 Differential Diagnosis of Postoperative Jaundice

Feature

Hemolysis

Ischemic hepatitis

Sepsis-related cholestasis

Obstruction

Bilirubin type

Unconjugated

Mixed

Conjugated

Conjugated

ALT/AST

Normal

↑↑↑

Mild ↑

Normal/mild ↑

ALP/GGT

Normal

Mild ↑

↑↑

↑↑↑

PT/INR

Normal

↑

↑

Normal

Imaging

Normal

Normal

Normal

Obstruction seen

 

 

🔷 Viva Pointers

  • Q: What is the most common cause of post-op jaundice in orthopedic surgery?
    • A: Hematoma resorption
  • Q: What liver function test pattern indicates ischemic hepatitis?
    • A: AST/ALT > 1000 IU/L, mild bilirubin rise
  • Q: When do you suspect biliary obstruction post-op?
    • A: Direct hyperbilirubinemia with raised ALP, GGT and dilated ducts on imaging