Ovarian mass, decompensated liver failure

53 year old women for laparoscopy and removal of ovarian mass

Background

  • Child pugh B liver cirrhosis secondary to hepatitis C
  • Ovarian mass with raised CA125
  • Seen in clinic in July 2021. Found to be in decompensated liver failure with ascites and right sided pleural effusion. 
  • Discussed with surgeon. For 3/12 deferral only to optimize liver disease.

Issues

  • Recent diagnosis – hepatitis C
  • Decompensated liver failure
  • Coagulation tests deranged 

Discussion

  • Patient delayed 3 months – has completed treatment for Hepatitis C. Will have further pathology testing and liver ultrasound in follow up after surgery.
  • Liver decompensation – treated with diuretics. Patient refused treatment with lactulose. Resolution of ascites and right sided pleural effusion
  • Coagulation test derangement – common in liver disease, note that bleeding is related to abnormal anatomy (oesophageal varices, gastric/duodenal ulcers) and not necessarily coagulopathy. Current INR = 1.4, platelet count = 60.
  • Is TEG useful to help guide management of bleeding? Discussion about it’s use before and/or during surgery.
  • What treatment should be given for abnormal coagulation studies prior to surgery?
  • Should she have regular Vitamin K?

Plan

  • Patient discussed with surgeon as did not have date as yet. Surgeon was grateful for call as there was limited availability of operating time and this patient’s outcome may be affected by further delay to surgery. 
  • Discussed with Haematology – they suggest that patient is unlikely to be coagulopathic. They state that recently released guidelines do not recommend platelet transfusion below levels of 50 in chronic liver disease who are not overtly bleeding, and that any FFP replacement is unlikely to significantly lower INR below 1.4 and not recommended in chronic liver disease (see DOI: 10.1111/jth.15562)
  • Vitamin K seems low risk – especially given orally, although not recommended in guidelines attached. 
  • TEG in cirrhosis – seems promising, although patients seem to have variable results. See extract from recent review, with conclusions below.