Bleeding in Cirrhotic Patients: A Precipitating Factor due to Intravascular Coagulation or to Hepatic Failure?

Abstract

In 24 cirrhotic patients at different stages of hepatic failure, factor VIII: C (F VIIl·C), factor VIΠR:AG (F VIIIR:AG), factor VIII AG/C ratio (F VIII AG/C), and serum fibrin-fibrinogen degradation products (FDP) were investigated. In 11 of the 24 patients, several instances of gastrointestinal bleeding due to esophageal varices rupture were documented and 5 patients died of unarrestable bleeding. In our study, we evaluated whether the cause of bleeding was the development of intravascular coagulation or the severity of hepatic failure. A statistically significant difference between F VIIl·C, F VIIIR:AG/C ratio, and serum FDP was found in bleeding in comparison with non-bleeding patients. An inverse correlation between the F VIII :C plasma level and serum FDP as well as a direct correlation between F VIII AG/C ratio and serum FDP in the group of bleeding patients were also found. These data seem to suggest a hypercoagulable state which was more significant in the 5 patients who died owing to bleeding. Furthermore, only 1 of these patients had severe hepatic failure. From this study it appears that, in cirrhotic patients, bleeding is related more to the appearance of disseminated intravascular coagulation, as a consequence of both hemodynamic and endothelial changes, than to the degree of hepatic failure itself.

Disseminated Intravascular Coagulation in Endemic Hepatosplenic Schistosomiasis

“…Each of these mechanisms might activate the coagulation system and subsequently stimulate fibrinoly sis leading to DIC. Exposure of circulating blood to the expanded collaterals and dis torted splenic circulation [47] and the hemo dynamic and endothelial changes caused by expanded collaterals leading to an increase in the blood surface area and activation of the contact phase of coagulation [48] might also play a role in the hemostatic abnormalities.…”

Transfusion strategies in patients with cirrhosis

“…63 It is under debate whether hyperfibrinolysis is directly related to gastrointestinal bleeding in patients with cirrhosis as all the studies attempting to address this issue are limited by their retrospective nature and small sample size. 34,64,65 Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that inhibits the conversion of plasminogen to plasmin by blocking binding of plasminogen with fibrin. It has been shown to reduce blood transfusions in patients undergoing emergency or urgent surgery, 66,67 decrease postpartum blood loss and prevent postpartum hemorrhage and blood transfusions.…”

Infection, coagulation, and variceal bleeding in cirrhosis

“…71 Features of DIC have been reported in cirrhotic patients with variceal haemorrhage, especially in those who die of continued bleeding, 72 where multiple transfusions may be a confounding factor. However, there is little evidence for DIC occurring as a primary event in cirrhosis.…”