Perioperative decision-making for patients with known alcohol-related liver disease undergoing emergency surgery

Identification and risk stratification

As with all aspects of preassessment for anaesthesia, early identification of issues enables preventive overreactive care. Harmful drinking and known ARLD constitute one area that needs identification in emergency populations, as well as the risk stratification of these patients prior to emergency surgery.

Figure 1

AUDIT-C score. Source: https://www.nice.org.uk/guidance/cg115 [9].

As laid out in the AoA 2025 perioperative guideline, all patients expecting to stay in hospital for more than one night should be screened using the AUDIT-C validated screening tool [8]. An initial AUDIT-C score of >5 should lead to the completion of the full AUDIT questionnaire by a healthcare professional to determine their perioperative risk. Please see Fig. 1 for a breakdown of the scoring system used in the AUDIT-C tool.

Full AUDIT scores of <8 are felt to be low risk. Scores of 8–19 comprise medium risk, with scores >19 consistent with harmful drinking and alcohol dependence [8]. In addition to high AUDIT scores, clinicians should be vigilant when checking for the stigmata of chronic liver disease, as well as comorbidities associated with harmful alcohol intake.

Identification of patients with harmful alcohol use or alcohol dependence should prompt further clinical evaluation. Full blood panels, including coagulation, haematinics, aspartate aminotransferase:alanine aminotransferase (AST:ALT) ratios and gamma-glutamyl transferase (gamma-GT) tests, should be ordered before the operation, if time allows. A baseline electrocardiogram should be performed to identify arrhythmias or cardiomyopathy. An urgent echocardiogram assessment should be considered if there is clinical suspicion of heart failure or systemic overload, as advised in the AoA guideline [7, 9].

Whilst helpful guidelines exist for the non-emergency setting, guidance on the management of these patients is less clear in the emergency setting. Patients with deranged liver function tests or clinical evidence of decompensated liver disease should be reviewed urgently with the local hepatology team, investigated appropriately prior to surgery and clinically optimised, as timing of surgery allows. A specialist input can guide nutritional, metabolic, fluid and haematological abnormalities in the perioperative period [6].

In helping to risk stratify these patients in their clinical context, the Veterans Outcomes and Costs Associated with Liver Disease – Penn (VOCAL-Penn) score can be used in conjunction with pre-existing general-purpose perioperative risk calculators, such as P-POSSUM and SORT, to help guide perioperative risk and timing of surgery. The VOCAL-Penn score is a cirrhosis-specific surgical risk scoring tool incorporating nine variables, and estimates 30-day and 60-day mortality and risk of postoperative decompensation. Whilst the Child–Turcotte–Pugh (CTP) score and the Model for End-Stage Liver disease (MELD) score are widely known systems used to predict the severity of liver disease and overall mortality risk, the VOCAL-Penn score aims to better predict postoperative mortality and decompensation in this patient cohort [10, 6]. Whilst now externally validated, the original derivation for VOCAL-Penn was based on male US veterans; it does not grade portal hypertension severity or general frailty score, some limitations of its design [11].

The VOCAL-Penn score is very helpful for conveying and communicating perioperative and mortality risk to both the patient and the multidisciplinary team. Please see Fig. 2 for the input calculator and domains used in the VOCAL-Penn score [12].

Figure 2

Data input for VOCAL-Penn scoring system. Source: https://www.vocalpennscore.com/ [12].

Without discrete value cut-offs, it should be used as an adjunct to clinical judgement, and aims to enable shared decision-making when balancing risk of surgery against the potential benefit of not operating. Uncontrolled decompensation, active hepatitis and severe thrombocytopenia represent reasons to delay emergency surgery if the clinical scenario allows and these are reflected within the VOCAL-Penn score [11].

Preoperative and postoperative harm reduction

Early identification and treatment of acute AWS is paramount for patients undergoing emergency surgery. Whilst not the focus of this article, recognised scoring systems, such as the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale, should be used to assess and guide management with benzodiazepines as per local protocol. For full details please refer back to the AoA consensus guideline on managing acute alcohol withdrawal in the perioperative period. Consideration should be given to nutrition and thiamine deficiency in the emergency setting, ensuring that thiamine is replaced before glucose is given to avoid precipitating Wernicke’s encephalopathy, optimising fluid status and electrolyte abnormalities [7].

Often the highest risk period for these patients is the postoperative period. Those individuals identified as high risk from the above criteria should be carefully monitored throughout the postoperative period. Patients at high risk of AWS should be closely monitored in a high dependency unit/intensive care unit setting, in case of rapid deterioration. Postoperative pain management can be an issue in this cohort, so multimodal analgesia should be used to avoid opioid tolerance, especially if AWS is diagnosed [13]. This cohort is also at increased postoperative infection and wound complications, and so there is further emphasis on nutritional optimisation and glycaemic control [14]. The importance of close nursing observation, monitoring of patient observations, blood results and the use of scoring systems, such as the CIWA-Ar score, with prompt clinician review and intervention are paramount in detecting and managing postoperative deterioration. Hallmark features of decompensation such as jaundice, ascites and encephalopathy should be closely monitored. Bowel function can be impaired by both immobility or postoperative ileus, or be medication induced, and should be a focus of postoperative management [15].

To summarise all of the above aspects of care in this patient cohort, it is of vital importance to rely on systems-level and multidisciplinary interventions. The role of ‘alcohol care teams’ has been shown to reduce readmissions and mortality and improve quality of alcohol care [16]. They can provide bridges between other specialist nurses and liaison psychiatry teams. These specialist teams are also able to screen, provide preoperative risk reduction intervention and enable continuity of care throughout a patient’s journey. They are key to contributing to effective and safe patient care during the perioperative period.

Whilst robust pathways exist in the elective setting, more comprehensive guidelines are needed for the emergency setting, with the latest AoA 2025 guideline bridging this gap [7]. This review article aimed to deliver insights towards outlining management priorities and risk stratification in emergency surgical patients to aid decision-making preoperatively and to ensure robust postoperative care in this patient cohort.

Research ethics statement

Not applicable to this article.

Consent for publication

This narrative article is based on a fictional clinical vignette and does not describe a real patient or clinical encounter so consent for publication is not necessary. Images are used solely for illustrative purposes and are not related to the vignette. Where real patient images are included, the authors confirm that written informed consent for publication has been obtained for this purpose in accordance with the journal’s patient consent requirements.

Conflicts of interest statement

Isra Hassan is AoA co-chair of the Working Party and lead author for the consensus guideline for the perioperative identification and management of patients with unhealthy alcohol intake (January 2025). Isra Hassan is an Advisory Board Member for Advances in Perioperative Care. The authors declare no further conflicts of interest.