The Complex Role of Anticoagulation in Cirrhosis: An Updated Review of Where We Are and Where We Are Going

Abstract

Venous thromboembolism (VTE) in cirrhotic patients is an increasingly encountered problem in the daily clinical practice; there is still a debate on the ideal measures to be followed for prophylaxis and treatment of VTE among this population. Although traditionally, liver cirrhosis has been considered a disease with hypocoagulability state and increasing bleeding tendency due to severe homeostatic disruption in liver disease, until recently there is increasing awareness and evidence that cirrhotic patients are not completely protected from thrombotic events although they have an elevated international normalized ratio and auto anticoagulation. Furthermore, hypercoagulability is now an increasingly recognized aspect of chronic liver disease (CLD), and the bleeding risk of VTE prophylaxis and treatment remains unclear. In this review, we provide an updated discussion on the mechanisms involved in hemostasis in CLD as well as on the benefits and complications of anticoagulant therapy in cirrhotic patients. Overall, sufficient evidence exists, promoting the use of anticoagulation in cirrhotic patients for both VTE prophylaxis and treatment in carefully selected patients after consideration of pharmacologic or endoscopic variceal bleeding prophylaxis.

Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study

“…In this study, we evaluated the risk factors associated with an exacerbation of PHE over the period of observation, and not the presence of PHE as per our previous study. Recently, Khoury et al [29] reviewed the clinical importance of venous thromboembolism including PS. Large EVs, PHG, PHC, a Child-Pugh system grade B or C severity of liver disease, prior history of endoscopic variceal injection sclerotherapy or ligation, and prior history of acute GI bleeding, as well as a high transient elastography score and a high CT score, have also been associated with an increased risk of PHE [14, 21-25].…”

Accidentally discovered Portal Vein Thrombosis before Splenectomy due to Hypersplenism - The role of Thrombogenic Genes Polymorphisms

“…Vitamin K antagonists have a rate of complete PV recanalization in cirrhotics between 40% and 45% after a mean duration 8.1 months of anticoagulation therapy [11]. The problem encountered is monitoring INR value which is altered in cirrhosis [5].…”

Drug-induced liver injury with oral anticoagulants: a threat or not?

“…In their  Heart  paper, , Alonso et al 8 report a real-world observational study exploring the risk of hospitalisation with liver injury in 113 717 new OAC users enrolled in two US administrative claims-based datasets, with a median 12-month follow-up. Half of the enrolees used warfarin, 27% received rivaroxaban, 15% dabigatran and 8% used apixaban.…”

“…Notably,~5% of new OAC users had previously known liver disease, but information on the aetiology or disease severity was unavailable 8. Advanced liver dysfunction is associated with increased risk of bleeding, but is also a prothrombotic disorder 9.…”