Autoimmune Hepatitis (AIH)

Quantify the liver, don't eyeball it - PT/INR, serum albumin, bilirubin, alkaline phosphatase, transaminases, and a CBC. AIH patients commonly carry a prolonged PT, hypoalbuminemia, leukopenia, a normochromic anemia, and thrombocytopenia. A sharp rise in alkaline phosphatase suggests primary sclerosing cholangitis overlap or hepatocellular carcinoma in advanced disease.

Coagulopathy and neuraxial - Have the INR and platelet count in hand before you offer an epidural or a deep block. The platelet count can be low from the disease itself and from azathioprine.

Varices - Once cirrhosis develops, these patients get surveillance upper endoscopy for esophageal varices. Know the last result before you pass an orogastric tube or a TEE probe, and be gentle when you do.

Encephalopathy - Serum ammonia is the lab to send in a patient with altered mental status, and it is usually elevated when hepatic encephalopathy is present. Find out whether they are on lactulose or rifaximin; a patient who is already encephalopathic will be slow to wake up.

Steroids are the backbone - Prednisone monotherapy induction is 60 mg daily for one week, 40 mg in week two, 30 mg in weeks three and four, with maintenance at 20 mg daily. Combination therapy uses lower-dose prednisone plus azathioprine 30 mg orally daily. Don't let the maintenance dose get skipped on the day of surgery.

Steroid fallout you meet in the room - Long-term corticosteroids bring cardiac arrhythmias, diabetes mellitus, hypertension, osteoporosis with fractures, cushingoid habitus, and cataracts. That means a baseline ECG for the arrhythmia and hypertension history, a glucose check, and deliberate padding and positioning for fragile bone and skin.

Azathioprine and the alternatives - Azathioprine causes cholestasis, pancytopenia, and pancreatitis, and patients on it get a routine CBC — pull the most recent one. When azathioprine fails or is not tolerated, mycophenolate mofetil, cyclosporine A, and tacrolimus are used instead; budesonide is the steroid-sparing alternative.

Immunosuppressed patient - Some patients stay on lifelong immunosuppression. Strict asepsis for lines and blocks, and treat a fever as real.

Pregnancy - Up to 20% of AIH patients flare during pregnancy, with a high rate of fetal and maternal complications. Prednisone alone or with azathioprine is continued through pregnancy and is compatible with breastfeeding; mycophenolate mofetil and tacrolimus are contraindicated. In cirrhotic pregnancy, upper endoscopy is done around 28 weeks — the point of maximum volume expansion — with prophylactic band ligation of high-risk varices. That is the window when a variceal bleed is most likely to land in your OR.

Decompensation - Treatment failure occurs in about 10% of treated patients. Watch for hepatic encephalopathy, hepatorenal syndrome, ascites, and variceal bleeding; those patients are on a transplant path and should be anesthetized as end-stage liver disease.

Bleeding varices - Immediate resuscitation, protection of the airway, then endoscopy with sclerotherapy or band ligation. Airway first, endoscopy second.

Autoimmune hepatitis (AIH) is chronic, progressive inflammation of the liver with no identified cause. The working model is genetic predisposition plus an environmental trigger plus failure of the native immune system, producing sustained hepatocyte inflammation and, over time, hepatic fibrosis. Two types are recognized, both characterized by circulating autoantibodies and elevated serum globulins. Most patients present with fatigue, malaise, jaundice, abdominal pain, and arthralgias; ascites, hepatic encephalopathy, and variceal hemorrhage are rare as an initial presentation but define the decompensated end of the spectrum. A minority present as acute liver failure with jaundice, ascites, and coagulopathy.

Everything that matters to us follows from two facts: the liver is failing, and the patient is on long-term immunosuppression.