Hemostasis, bleeding and thrombosis in liver disease

Abstract

The presence of cirrhosis poses an increased risk of both thrombosis and bleeding in individuals with chronic liver disease. This duality is a result of a dynamic disequilibrium between procoagulant and anticoagulant states in individuals with cirrhosis. The mechanism of this imbalance in cirrhosis remains unclear. It is known that the progression of cirrhosis leads to decreased synthetic function and a concurrent lack of natural anticoagulants. Other proposed mechanisms contributing to this hemostatic imbalance include decreased platelet production, increased platelet destruction from hypersplenism, decreased synthesis of Vitamin K-dependent and independent clotting factors and anticoagulant factors, and alterations in purinergic signaling pathways.Given the current state of flux in our understanding of bleeding and thrombophilia in cirrhosis, the recommendations for treatment of these conditions are still evolving.We provide a current update on the proposed pathophysiology of altered hemostasis and thrombophilia in cirrhosis. We discuss recent studies in portal vein thrombosis (PVT) and venous thromboembolism (VTE), which are the common thrombotic consequences of cirrhosis, resulting in substantive morbidity and mortality. To address these, we discuss new prophylactic interventions and current treatment options to manage the heightened risk of thrombosis in cirrhosis, while limiting hemorrhagic complications.

Evaluation of Coagulation, Fibrinolysis and Endothelial Biomarkers in Cirrhotic Patients With or Without Portal Venous Thrombosis

“…This duality is a result of a dynamic disequilibrium between pro- and anti-coagulant factors in cirrhotic patients. 14 Although a hemostatic balance is reached in cirrhosis, this equilibrium is more fragile and can easily lead to a hypo- or hyper-coagulable state. 15 In recent years, it has been evident that appropriately assessing patients for the risk of bleeding and thrombosis cannot be done with standard coagulation tests, such as PT, INR or APTT.…”

Ramadan fasting and liver diseases: A review with practice advices and recommendations

“…There is a cumulative evidence in the literature documenting high prevalence of asymptomatic peptic ulcers in cirrhotic patients diagnosed accidentally 44,45 . As mentioned, before there is an increase in the gastric acid and pepsin secretion during the daytime, and frequently there is an underlying coagulopathy and thrombocytopenia among cirrhotics 46 and, hence, there is a real risk for peptic ulcer bleeding among cirrhotics. Consequently, clinicians should think in a screening endoscopy for asymptomatic cirrhotic patients – together with other evaluations – before allowing them to fast (Figure 1).…”

Peeking at the right heart at the right moment: a giant thrombus in transit

“…This patient, having both type A and C thrombi, presented multiple risk factors for venous thrombosis and also in situ right atrial thrombus formation 3 4…”

“…Optimal treatment of RiHT is controversial, spanning anticoagulation, fibrinolysis and percutaneous or surgical thrombectomy. Anticoagulation may be enough in haemodynamically stable patients,5 especially in patients with a higher bleeding risk due to acute hepatic failure 3…”