Liver disease induced coagulopathy

Background

Liver vascular anatomy.

Differential Diagnosis

Coagulopathy

Platelet Related

• Too few
  • Thrombocytopenia
• Nonfunctional
  • Aspirin
  • Von Willebrand disease

Factor Related

• Acquired (Drug Related)
  • Warfarin (Coumadin)
  • Unfractionated heparin
  • Low molecular weight heparin (i.e. enoxaparin (Lovenox), dalteparin)
  • Factor Xa Inhibitors (e.g. rivaroxaban, apixaban, fondaparinux, edoxaban)
  • Direct thrombin inhibitors (e.g. dabigatran, argatroban, bivalirudin)
• Illness induced
  • Vitamin K deficiency
  • Disseminated Intravascular Coagulation (DIC)
  • Liver disease induced coagulopathy
  • Uremic bleeding syndrome
• Genetic
  • Hemophilia
  • Factor VIII inhibitor
  • Lupus anticoagulant

Evaluation

• PT prolongation
  • Decreased synthesis of vitamin K-dependent factors (II, VII, IX, X)
• Thrombocytopenia
  • Portal hypertension → congestive hypersplenism → splenic sequestration
• Fibrinolysis increased
  • Due to decreased synthesis of alpha2 plasmin inhibitor
  • Low fibrinogen level, mild elevation of FDP and D-dimer

Management

Lab abnormalities only (with out significant bleeding)

• Observation

Significant bleeding

• Vitamin K PO or IV
• Desmopressin
  • Effective with minimal side effects
  • 0.3mg/kg IV (preferred) or SC (max 20mg)
  • Onset of action ~1hr, duration of action ~4-24hr
• Cryoprecipitate
  • May be used to replace fibrinogen in patients with fibrinogen levels <100
  • 1 bag per 10kg of body weight
• Platelets
  • Aim for >50K for moderate risk procedures; >100K for high risk procedures
• FFP
  • Use with caution; requires large volume of FFP to make a significant difference
• PPI/famotidine/octreotide (variceal bleeding)

See Also

• Coagulopathy (Main)