Introduction : The presence of portal hypertension,gastric and oesophageal varices can result in catastrophic gastrointestinal haemorrhage.Patients with liver disease are at particularly high risk for morbidity and mortality in the postoperative period due to the stress of surgery and effects of general anaesthesia.Obesity is a multi-system disorder, particularly involving the respiratory and cardiovascular systems.Stenoticvalvular heart disease patients are at risk of lnfectiveendocarditis,have a fixed cardiac output and unable to compensate for the reduction in systemic vascular resistance caused by thevasodilating effect of general anaesthetics.This can sometimes have disastrous consequences.

Case report : A 63years old male patient presented with low backache and dragging pain in left lower limb since 1month. History revealed that he was diagnosed to have Chronic liverdisease,morbid obesity and Rheumatic heart disease.On examination patient had bilateral pitting oedema,BMI=36.1.Abdominal distention ,engorged veins,shifting dullness present on per abdomen examination.Investigations revealed Hb 10.5 g%, Platelets 1.38,PT/INR 1.24,HBsAg positive ,LDH 428U/L, USG abdomen showed portal hypertension, cirhosis of liver,oesophagealvarices.Echocardiogram revealed RHD with AS,AR and MR. A provisional diagnosis of Intervertebral Disc Prolapse L3-L4 & L4-L5 level was done, posted for laminectomy and discectomy under general anaesthesia and patient was accepted under ASA III with high risk.

Conclusion : Due to high mortality rate associated with the potential complications of portal hypertension and Rheumatic heart disease multidisciplinary management should be implemented,Goals include:preoperativeassessment,endocarditisprophylaxis,maintaining hemodynamic stability,optimal mode of analgesia/anaesthesia and post operative monitoring with prompt decisions gave a good outcome in this patient.