57-year-old female with an ovarian mass for Investigation.
- Liver disease
- Long history of untreated HCV
- Now diagnosed with Childs Pugh B liver cirrhosis – albumin 20, bilirubin 64, platelets 57.
- Recent admission with decompensation – severe hydrothorax treated with diuretics.
- Antivirals recently commenced but not with curative intent.
- Letters suggest gastro teams and gynae team all aware of both issues.
- Ovarian mass
- Incidental finding although some abdominal discomfort
- Ca125 274 (could be elevated due to liver disease)
Should surgery proceed?
- Cirrhosis surgery risk score (http://www.vocalpennscore.com) suggests:
- 30d mortality of 7%
- 6/12 mortality 19%
- Phone call to gastroenterology team:
- High risk of haemorrhage (very difficult to control) with any abdominal surgery, especially laparoscopic, due to portal hypertension.
- High risk of postoperative decompensation, encephalopathy, infection, and wound breakdown.
- Patient requires urgent variceal banding, but this will worsen portal hypertension.
- Delay of 2/12 to enable gastroscopy, ongoing antiviral treatment, anti-portal HTN treatment, repeat imaging, and possible mild improvement.
- General opinion at the meeting was that the real risks highlighted by the gastroenterologist superseded the theoretical risks of a delayed diagnosis of a possible ovarian cancer (patient unlikely to be a candidate for radical curative surgery or chemotherapy). See attached summary article.
- TIPS (or similar procedure) may be an option to offload portal hypertension prior to consideration for gynae surgery – for further discussion after 2/12 delay.