Treatment of bleeding in patients with liver disease

Abstract

Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure-related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post-procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.

Keywords: antifibrinolytic agents; blood transfusion; platelet transfusion; portal hypertension; prothrombin time.

FIGURE 1

Common sources of bleeding in patients with cirrhosis. Many bleeding events are due to spontaneous mechanical sources such as ruptured esophageal varices while others are related to related to trauma to blood vessels and tissues, often related to medical interventions. The minority of bleeding events are purely due to the hemostatic failure of end stage liver disease. Figure adapted from Northup, et al. Used with permission.

FIGURE 2

Evaluation and treatment schema for bleeding in a patient with cirrhosis. Abbreviations: VET: viscoelastic testing.