Coagulopathy in Cirrhosis

Chapter

Abstract

The liver plays an integral role in hemostasis and is responsible for the synthesis of the majority of procoagulant, anticoagulant, and fibrinolytic proteins. Liver dysfunction disrupts this process, altering the normal hemostatic balance. Historically, liver disease was felt to represent a bleeding diathesis. More recently, evidence supports a model of rebalanced hemostasis where concomitant prohemostatic and antihemostatic changes lead to a rebalancing of the hemostatic system; however, this balance is far more unstable compared to healthy individuals and is easily shifted in either direction. Unfortunately, no one test can accurately predict the risk of bleeding or thrombosis in liver disease. The prothrombin and activation partial thromboplastin times, platelet count, and fibrinogen are commonly used tests, but they assess only a single aspect of the hemostatic system, which is not ideal in chronic liver disease. Global tests of hemostasis, such as thromboelastography, represent a method of measuring whole-blood coagulation. A variety of options are available for the treatment and prevention of bleeding and thrombosis in chronic liver disease. Bleeding is often treated with red blood cells, platelets, fresh frozen plasma, and cryoprecipitate. Recombinant factor VIIa and prothrombin complex concentrates should be reserved for refractory, or life-threatening bleeding. Portal venous thrombosis is the most common thrombotic event in liver disease, and whether or not treatment is necessary is often unclear. Furthermore, deciding which anticoagulant to use can be difficult. Interpreting normal measures of anticoagulation, such as INR and anti-Xa levels, is often problematic in chronic liver disease. Last, accumulating evidence supports thromboprophylaxis in hospitalized patients with chronic liver disease due to an increased risk of thrombosis.

Keywords

Cirrhosis Coagulopathy Hemostasis Thrombosis Thrombocytopenia 

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Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of MedicineUniversity of Pittsburgh, Hemophilia Center of Western PennsylvaniaPittsburghUSA

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