Superimposed coagulopathic conditions in cirrhosis: infection and endogenous heparinoids, renal failure, and endothelial dysfunction

Enteric tube placement in patients with esophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding

Background and Aim

Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement.

Methods

We performed a retrospective chart review on patients requiring ET access with known EV. Inclusion criteria were age >18 with endoscopically proven EV who required ET placement. Patients who were admitted with, or developed a GIB prior to placement of ET were excluded, as were patients admitted for liver transplantation. Primary outcome was incidence of GIB within 48 h of tube placement. Secondary outcome was a >2 g/dL drop in hemoglobin within 48 h of placement without evidence of bleed. Statistical analysis was performed using Fischer's exact test, Mann-Whitney U test, and univariate logistic regression model.

Results

A total of 75 patients were included in the analysis. The most common etiology of cirrhosis was alcohol (44%). The most common location of EV was in the lower third of the esophagus (61%). The primary outcome was observed in 11 (14.6%) patients. The secondary outcome was found in eight (10.6%) patients. On univariate analysis, GIB was associated with higher MELD-Na (P = 0.026) and EV located in the lower third of the esophagus (P = 0.048).

Conclusion

ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.

Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease

The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.

Hepatic coagulopathy-intricacies and challenges; a cross-sectional descriptive study of 110 patients from a superspecialty institute in North India with review of literature

Hemostatic defect in chronic liver disease (CLD) is complex involving opposing factors of primary hemostasis, coagulation, and fibrinolysis. The concept of causal relationship between abnormal tests and clinical bleeding is unclear. This study was undertaken to evaluate and correlate clinical bleeding and the commonly used laboratory tests for hemostasis in CLD patients including the subgroup of acute on chronic liver failure (ACLF) patients and test the reproducibility of international normalized ratio (INR) using different reagents. This was a cross-sectional descriptive study wherein clinical records and laboratory data from 110 patients (95 CLD, 15 ACLF) over a 6-month period were analysed. Variceal bleeding (33.3%) was the commonest followed by mucosal/skin bleeds (5.4%). Thrombocytopenia seen in 70.9% patients was mostly mild (48.2%) to moderate (14.5%). Prothrombin time (PT) prolongation was seen in 81.8% with significant variation in PT/INR using different reagents. Adverse outcome in the form of disseminated intravascular coagulation, septic shock or death was seen in 13.6% patients (eight ACLF and seven CLD). There was no correlation of bleeding with prolonged PT/INR, decreased platelet count and adverse clinical outcome. However, individually, there was significant but weak correlation between variceal bleeding and lower platelet count and superficial bleeding and prolonged PT. Correction of PT/INR post-fresh frozen plasma was significant but platelet count postplatelet concentrate transfusion was not. ACLF patients compared with CLD patients had greater PT prolongation and adverse outcome but no increase in bleeding. Routine tests, although globally deranged inadequately reflect haemostatic imbalance in CLD and poorly predict bleeding risk.

Management of coagulopathy in patients with decompensated liver cirrhosis

Patients with decompensated liver cirrhosis have significantly impaired synthetic function. Many proteins involved in the coagulation process are synthesized in the liver. Routinely performed tests of the coagulation are abnormal in patients with decompensated liver cirrhosis. This has led to the widespread belief that decompensated liver cirrhosis is prototype of acquired hemorrhagic coagulopathy. If prothrombin time is prolonged more than 3 seconds over control, invasive procedures like liver biopsy, splenoportogram, percutaneous cholangiography, or surgery were associated with increased risk of bleeding, and coagulopathy should be corrected with infusion of fresh frozen plasma. These practices were without any scientific evidence and were associated with significant hazards of fresh frozen plasma transfusion. Now, it is realized that coagulation is a complex process involving the interaction of procoagulation and anticoagulation factors and the fibrinolytic system. As there is reduction in both anti and procoagulant factors, global tests of coagulation are normal in patients with acute and chronic liver disease indicating that coagulopathy in liver disease is more of a myth than a reality. In the last few years, surgical techniques have substantially improved, and complex procedures like liver transplantation can be done without the use of blood or blood products. Patients with liver cirrhosis may also be at increased risk of thrombosis. In this paper, we will discuss coagulopathy, increased risk of thrombosis, and their management in decompensated liver cirrhosis.

Endogenous heparinoids induced massive hemorrhage postoperatively following THA

A 64-year-old woman presented with right hip pain of 6 years' duration, accompanied by limping of 1 years' duration. Preoperative pelvis radiograph showed narrowing of joint space, osteophyte formation, and cystis degeneration of the femoral head surrounded by bony sclerosis, without obvious collapse of the femoral head; the diagnosis was osteoarthrosis. The patient's blood pressure on admission was 128/76 mm Hg. The patient had no special previous history. Preoperative blood and coagulation tests were normal. Total hip arthroplasty was performed via a posterolateral approach, and intraoperative bleeding was 400 mL. In the first 10 hours postoperatively, the drainage volume decreased slowly, the initial dose of 0.3 mL Fraxiparine was administered, and the blood pressure was 84∼92/45∼56 mm Hg. The drainage volume increased gradually, and 10 hours after administration of Fraxiparine, the drainage volume increased sharply and maintained at a high level. Protamine was applied and the drainage volume decreased sharply, furthermore, a high concentration of endogenous heparinoids were detected in the blood. Although no direct evidence were detected, it was clear that the massive hemorrhage was associated with administration of low-molecular-weight heparin (LMWH). The administration of LMWH combined with continuous low blood pressure caused by surgery and massive bleeding that resulted in low perfusion and inflammation in microcirculation, induced endogenous heparinoid synthesis in endothelial cells, and elevated concentration of endogenous heparinoids in blood led to more severe bleeding. Therefore, caution should be taken with administration of anticoagulant therapy in patients with massive hemorrhage, especially in patients with continuous low blood pressure.

Management of coagulopathy in patients with decompensated liver cirrhosis

Patients with decompensated liver cirrhosis have significantly impaired synthetic function. Many proteins involved in the coagulation process are synthesized in the liver. Routinely performed tests of the coagulation are abnormal in patients with decompensated liver cirrhosis. This has led to the widespread belief that decompensated liver cirrhosis is prototype of acquired hemorrhagic coagulopathy. If prothrombin time is prolonged more than 3 seconds over control, invasive procedures like liver biopsy, splenoportogram, percutaneous cholangiography, or surgery were associated with increased risk of bleeding, and coagulopathy should be corrected with infusion of fresh frozen plasma. These practices were without any scientific evidence and were associated with significant hazards of fresh frozen plasma transfusion. Now, it is realized that coagulation is a complex process involving the interaction of procoagulation and anticoagulation factors and the fibrinolytic system. As there is reduction in both anti and procoagulant factors, global tests of coagulation are normal in patients with acute and chronic liver disease indicating that coagulopathy in liver disease is more of a myth than a reality. In the last few years, surgical techniques have substantially improved, and complex procedures like liver transplantation can be done without the use of blood or blood products. Patients with liver cirrhosis may also be at increased risk of thrombosis. In this paper, we will discuss coagulopathy, increased risk of thrombosis, and their management in decompensated liver cirrhosis.