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CASE REPORT
Anesthesia for a long-term anorexic patient with end-stage
liver cirrhosis : A Case Report
Kayo Hirose*, Makoto Ogura†, and Yoshitsugu Yamada‡*Department of Anesthesiology, Tokyo University Graduate School of Medicine, Tokyo, Japan, Department of Anesthesiology, Tokyo Metropolitan

Geriatric Hospital, Tokyo, Japan, †Department of Anesthesiology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan, ‡Department of Anesthesiology, Tokyo University Graduate School of Medicine, Tokyo, Japan

Abstract : Recent advancements in intensive care have increased the number of severe anorexia nervosa patients presenting for surgery. We provided anesthesia to a patient who had a 22-year history of anorexia withlife-threatening cirrhosis. Although surgery should be avoided in patients with end-stage cirrhosis, she was in
the best preoperative optimized condition compared to her condition over the past few years. Potential complications are heart failure easily caused by deterioration of cirrhosis, lethal arrhythmias related to electrolyte
disturbances and increased myocardial sensitivity to drugs, and refeeding syndrome in the postoperative period.
The several rare events that we experienced are worth reporting. J. Med. Invest. 66 : 337-339, August, 2019
Keywords : anorexia, end-stage liver cirrhosis, anesthesia

INTRODUCTION
With an increase in the prevalence of anorexia nervosa (AN),severe AN patients have been presenting for surgery since the2000s. (1) Patients with a long history of severe AN show several complications, such as acute liver injury, cardiovascularcomplications, pancytopenia, etc. However, only a few cases ofliver cirrhosis have been reported. We experienced a patientwith a long history of AN and life-threatening cirrhosis whorequired anesthesia. We share here our experience with thepreoperative evaluation, perioperative events and managementof this patient. The patient and her husband have provided“written consent”

CASE REPORTA 43-year-old female with a 22-year anorectic history wasscheduled for endoscopic submucosal dissection for esophageal
cancer. Her body mass index was 15.5 kg/m2 (height 148 cm ;weight 34 kg). Among her physical symptoms related to the long
history of anorexia, cardiovascular complications and Child C
cirrhosis appeared to be the biggest problems from the point ofview of anesthesia and the endoscopic procedure.
Her preoperative data related to the cardiovascular complications were as follows. Her blood pressure was 81/59 mmHg andheart rate was 99 beats per minute, indicating a class II shockindex of 99/81 = 1.2. Preoperative echocardiography revealed ashrunken heart, redundant mitral valve and pericardial effusion. She had a history of high output heart failure with pulmonary hypertension since one year.
Her Child-Turcotte-Pugh (CTP) score was 12 (class C) andthe model of end-stage liver disease (MELD) score was 15.
According to standard guidelines, patients with MELD scores
Received for publication February 6, 2019 ; accepted March 19, 2019.
Address correspondence and reprint requests to Kayo Hirose, Department of Anesthesiology, Tokyo University Graduate School ofMedicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan andFax : +81-3-5800-8938

above 15 should be considered for transplant. According to theMayo Natural History Model for Primary Biliary Cirrhosis,
the estimated 1-year and 5-year survival probabilities without
treatment in such patients are 58% and 1%, respectively. Dueto the cirrhosis, her prothrombin time-international normalized
ratio was prolonged to 1.5 and blood platelet count was decreased
to 6.4 × 104 /μL. Thoracic and abdominal computed tomography
revealed ascites and pericardial effusion. Although she had arepetitive history of hepatic encephalopathy, she had not had anepisode of encephalopathy since she got married the previousyear, and her preoperative ammonia level was normalized at 41
μg/dL (12–66). Other laboratory data related to liver function
were aspartate aminotransferase (AST) level of 43 IU/L, alanineaminotransferase (ALT) of 28 IU/L, γ-glutamyltransferase of 35
IU/L, albumin of 2.6 g/dL and total bilirubin of 3.0 mg/dL.
Additional significant preoperative data were hemoglobin 11.2g/dL, creatinine 1.44 mg/dL, potassium 3.4 mEq/L, phosphate
2.8 mg/dL ( < 2.3) and magnesium 1.0 mg/dL (1.9–2.5). Rapid
turnover protein levels were prealbumin 7.3 mg/dL (22.0–34.0),
retinol binding protein 1.2 mg/dL (1.9–4.6) and transferrin
75 mg/dL (190–320). She had repeated histories of electrolyte
disturbances, including potassium levels of 2.0 and 1.6 mEq/L,
respectively, at the ages of 41 and 42 years. Fortunately, herelectrolytes, except magnesium, had normalized over the year
after her marriage.
Before induction of anesthesia, 100 µg fentanyl was injected.
For induction of anesthesia, awake intubation was planned andadministration of anesthetic agents was minimized, including
minimum propofol usage and avoidance of muscle relaxants, inview of the loss of muscle mass caused by longstanding malnutrition and abnormal serum magnesium levels. Minimizing thepropofol dose also helped obviation of hemodynamic collapse.
We used electrocardiogram, non-invasive blood pressure, pulse
oximeter and arterial pressure-based cardiac output monitoring
system, FloTrac. Before anesthesia induction, Cardiac Index(CI) and Stroke Volume Variation (SVV) were 5.5 L/min/m2
and 3%, respectively. No hemodynamic change was observed
after awake intubation, but hypotension (BP : 60/35 mmHg) was
triggered following injection of 20 mg propofol, with a decrease in
CI to 3.0 L/min/m2 and elevation of SVV to 30%. Phenylephrine
was given to increase peripheral vascular resistance and restore

The Journal of Medical Investigation Vol. 66 2019

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K. Hirose, et al. Anesthesia in a severe anorexic with cirrhosis

hemodynamic stability. Anesthesia was maintained with 0.61.2% sevoflurane without a muscle relaxant. Intraoperatively, 25and 100 µg fentanyl was injected twice when the patient moved
or blood pressure was elevated, although with resultant hypotension each time. However, no major complications occurred.
After the procedure, the patient was successfully extubatedbecause spontaneous breathing had been maintained during theoperation.
Postoperatively, based on the National Institute for Healthand Care Excellence (NICE) guidelines for monitoring of refeeding syndrome, serum phosphate levels were measured daily
from postoperative days (POD) 1 to 4, which indicated serum
phosphate levels of 3.3, 2.2, 2.5 and 3.1 mg/dL, respectively. OnPOD 2, although phosphate levels decreased to below the lower
limit of normal, she did not develop refeeding syndrome. The
score gradually recovered over the following days and the patient
was discharged on POD 4.

DISCUSSION
We describe a patient with a long history of AN accompanied
by end-stage cirrhosis. (2) The patient had a high risk of mortality in the perioperative period, due to potential complications
related to the cardiovascular system, hepatic failure and postoperative refeeding.
The expected cardiovascular complications were heart failure
and lethal arrhythmias. Patients with severe AN have a low
cardiac output and increased peripheral vascular resistance.
(3) In contrast, patients with cirrhosis have a hyperkinetic andhyperdynamic circulation with tachycardia, low systemic bloodpressure and splanchnic vasodilatation. (4) Our patient had developed high output heart failure the previous year as a result of
the excessive vasodilatation and increased cardiac output, whichcaused imbalance between oxygen demand and supply. Exacerbation of cirrhosis and AN-related vitamin B1 deficiency seemed
to cause high output heart failure. (5) We were concerned about
our patient developing heart failure in the perioperative period,
because anesthetic agents tend to decrease cardiac output anddilate blood vessels. In fact, our patient showed dramatic reduction in CI and had increased SVV on induction of anesthesia.
Appropriate precautions and prompt correction of hemodynamicchanges were important in preventing perioperative heart
failure.
Another probable cause of heart failure in such patients isaltered transmitral flow, such as with mitral valve prolapse,
mainly because of leaflet-to-left ventricular size mismatch. (6)In patients with a long history of AN, the heart shows structuralatrophy that may be related to longstanding hypovolemia. Although our patient did not exhibit mitral prolapse, a redundant
mitral valve was observed on echocardiography. We consider it is
the most important not to change fluid condition among preoperative state, intraoperative state and postoperative. Vasodilationinduced with anesthetic agent were managed only by vasopressor and fluid infusion were avoided.
In severe AN patients, lethal arrhythmias are easily inducedby the administration of neostigmine, edrophonium or catecholamines, because of increased cardiac sensitivity. (1) Moreover,
our patient was in danger of life-threatening arrhythmias, suchas torsades de pointes or ventricular fibrillation, due to her pasthistory of extreme hypokalemia of 1.6 mEq/L. Light anesthesia
and avoidance of catecholamines, with judicious use of phenylephrine as needed, succeeded in preventing life-threatening
arrhythmia during the endoscopic procedure. (4) The muscle
relaxants, vecuronium and rocuronium, were avoided because
they are metabolized exclusively by the liver and because it would

have been difficult to administer neostigmine as the neuromuscular antagonist. (7,8) As mentioned above, lethal arrhythmias
are easily induced by the administration of neostigmine. We did
not want to use rocuronium and sugammadex because there are
only few reports of the use of these drugs in severe AN patients.
(1) In the immediate postoperative period, we strictly monitored
and maintained serum potassium levels in the normal range.
Ninety-day postoperative mortality in patients with CTP class
C and MELD score 15–19 are reportedly 54.5% and 14.3%,respectively. (9) Surgery should be avoided if possible in patientswith cirrhosis who are child class C or have a MELD score ofmore than 15. (4) Complications secondary to acute liver failureoften result in postoperative death. Hence, preoperative optimizations are recommended, including control of ascites, correctionof electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. (10) Our
patient was in better condition at the time of surgery comparedto the previous few years, with recovery from encephalopathy,
normalization of electrolytes, decrease of pericardial effusion andimproved dietary intake. Serous effusion caused by hepatic hypoproteinemia and longstanding anorexia had also decreased. (6)Yet, the patient was considered high risk in the postoperative period, because of the probability of developing refeeding
syndrome because of longstanding malnutrition. Refeeding
syndrome is induced by reintroduction of nutrition to a fasting
person. Rapid increase of insulin stimulates the movement of
extracellular phosphate, potassium and magnesium into the intracellular compartment, which results in rapid decrease in theextracellular concentration of electrolytes. Hypophosphataemia
induces lack of adenosine triphosphate and 2,3-diphosphoglycerate, with a consequent deficiency of energy itself. Any patientwith negligible food intake for more than five days is at riskof developing refeeding problems. Our patient developed mild
hypophosphataemia (0.6–0.85 mmol/L) on postoperative day 2,
after 3.5 days of fasting. According to NICE guidelines, the patient was given phosphate 0.3–0.6 mmol/kg/day orally to prevent
refeeding syndrome. (11)In conclusion, anesthesia and surgery in anorexic patients
can precipitate severe complications. Hence, we performed theless invasive treatment of endoscopic submucosal dissection forour patient’s esophageal cancer. The patient herself wished toundergo the endoscopic procedure. Our patient was successfully
managed with preoperative optimization, appropriate intraoperative precautions and postoperative monitoring.

DECLARATION OF INTERESTS
None of the authors have any conflicts of interest.

DETAILS OF AUTHORS’ CONTRIBUTIONS
K.H. : Performed perioperative management and wrote thepaper ; M.O. : Performed anesthesia with K.H. ; Y.Y. : Gave advice for writing the paper.

CONSENT FOR REPORTING THIS CASE
Permission was obtained from the patient for submission ofher case report for potential publication.

The Journal of Medical Investigation Vol. 66 August 2019
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