Antiplatelets and Antithrombotics in Patients with Liver Insufficiency: From Pathophysiology to Clinical Practice

Blood Disorders in Patients with Obstructive Jaundice: A Literature Review

BACKGROUND: Mechanical jaundice is a pathological syndrome consisting in a violation of the outflow of hepatic bile through the bile ducts into the duodenum due to mechanical obstacles. The most common causes of mechanical jaundice are gallstone disease, malignant tumors, as well as cicatricial stricture of the bile duct or the large duodenal papilla of the duodenum. All this leads to the development of renal-hepatic insufficiency. Thrombohemorrhagic changes develop in the vascular bed, leading to the development of disseminated intravascular coagulation syndrome. Prevention and treatment of cholemic bleeding in case of mechanical jaundice remains one of the complex problems of hepatobiliary surgery. This article is an overview of the causes and pathophysiological changes affecting hemostasis in mechanical jaundice, as well as the main points of treatment of hemostasis disorders in patients with mechanical jaundice. AIM: This study aims to study the literature on homeostasis in patients with mechanical jaundice. SEARCH STRATEGY: To conduct a systematic search for scientific information and to achieve this goal, an analysis of scientific publications in evidence-based medicine databases (PubMed), using specialized search engines (Google Scholar) and in electronic scientific libraries (CyberLeninka, e-library) was carried out from 2005 to 2020. INCLUSION CRITERIA: Research of high methodological quality: Meta-analysis, systematic review and cohort studies, as well as publications with clearly formulated and statistically proven conclusions in English, Russian, and Kazakh. EXCLUSION CRITERIA: Summaries of reports, reports in the form of abstracts, and advertising articles. RESULTS: The mechanisms that affect hemostasis in obstructive jaundice can be considered from four perspectives: The first relates to Vitamin K deficiency in obstructive jaundice, the second describes the effect of ongoing fibrosis and cirrhosis of the liver on hemostasis, the third analyzes the relationship between infectious-septic mechanisms and the hemostasis system, their clinical significance in patients with obstructive jaundice, and the latter involves the analysis of specific factors that manifest obstructive jaundice and may themselves affect the blood coagulation system. CONCLUSION: Understanding the pathophysiology of hemostatic changes in patients with cholestasis and, more generally, liver disease is a clear way to accurate diagnosis and treatment. The combination of good knowledge with careful examination of each patient can lead to the most promising result.

Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis

Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.