Thrombelastographic changes and early rebleeding in cirrhotic patients with variceal bleeding

Abstract

Background-Routine coagulation tests do not necessarily reflect haemostasis in vivo in cirrhotic patients, particularly those who have bleeding varices. Thrombelastography (TEG) can provide a global assessment of haemostatic function from initial clot formation to clot dissolution. Aim-To evaluate TEG changes in cirrhotic patients with variceal bleeding and their association with early rebleeding. Patients/Methods-Twenty cirrhotic patients with active variceal bleeding had serial TEG and routine coagulation tests daily for seven days. The TEG variables before the day of rebleeding (n = 6) were compared with those of patients without rebleeding (n = 14). Results-Baseline characteristics of the rebleeding and non-rebleeding groups were comparable apart from a higher incidence of uncontrolled infection on the day of rebleeding in the rebleeding group (p = 0.007). The patients in the rebleeding group were more hypocoagulable before the day of rebleeding as shown by longer r (42 v 24 mm, p<0.001) and k (48 v 13 mm, p<0.001) and smaller a (12 v 38°, p<0.001) compared with the mean of daily results of the non-rebleeding group. Routine coagulation tests, however, showed no significant diVerences between the two groups. Conclusion-The results of serial TEG measurements suggest that hypocoagulability may be associated with early rebleeding in cirrhotic patients. (Gut 1998;43:267-271)

Coagulopathy in liver disease: a balancing act

“…Cirrhotic patients with active variceal bleeding who experienced early re-bleeding had significantly more hypocoagulable TEG parameters than those who did not. 27 However, there are no prospective studies validating the accuracy of TEG or ROTEM for predicting procedural bleeding risk in patents with liver disease.…”

“…Bacterial infections may act as a trigger for variceal bleeding and are associated with failure to control bleeding. 27 Bacterial endotoxin induced nitric oxide and prostacyclin may impair platelet aggregation. Endotoxin may also release endogenous heparinoids, the glycosaminoglycans that maintain the physiologic antithrombotic surface of the endothelium.…”

Endogenous Heparinoids Detected by anti-Xa Activity are Present in Blood during Acute Variceal Bleeding in Cirrhosis. A Prospective Study

“…In contrast with previous results [5], anti-Xa activity was found in infected patients without cirrhosis [4], suggesting that the mechanisms involved might be independent of cirrhosis. In a prospective study, TEG parameters deteriorated before the day of re-bleeding in all 6 patients with rebleeding of 20 patients with variceal bleeding, compared with those without re-bleeding [15]; patients who re-bled had a higher incidence of uncontrolled infection on the day of re-bleeding. Moreover, a heparin e ect detected by raised anti-Xa levels was documented [6] immediately a er the bleeding episode in two variceal bleeders, which persisted for 5 days, over a similar time course of antibiotic treatment.…”

Hemostasis, Disorders of Coagulation and Transfusion in Cirrhosis

“…Before initiation of the test, provide a global assessment of haemostatic function from initial clot formation to clot dissolution, serial TEG measurements can be suggestive of hypocoagulability which may be associated with early rebleeding in cirrhotic patients [32]. The normal TEG tracing in comparison with abnormal tracings is shown in Figure 5.…”