Review

Cirrhotic coagulopathy: A rebalanced hemostasis

Achintya D. Singh, MD, MBBS, Simon R. Mucha, MD and Christina C. Lindenmeyer, MD
Cleveland Clinic Journal of Medicine September 2022, 89 (9) 523-533; DOI: https://doi.org/10.3949/ccjm.89a.21018

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Coagulation and anticoagulation in patients with cirrhosis are rebalanced due to simultaneous decreases in clotting and anticlotting pathways. However, this balance is dynamic, and concomitant conditions such as infection and acute kidney injury can tip the balance, resulting in a clotting or bleeding complication. (ADAMTS13 = a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13)

  • Figure 2
    Figure 2

    The 3 phases of coagulation, involving a range of clotting factors (as Roman numerals).

    HK = high-molecular-weight kininogen; tPA = tissue plasminogen activator; uPA = urokinase plasminogen activator

  • Figure 3
    Figure 3

    Thromboelastography is a promising test of coagulation. The horizontal axis represents time, the vertical axis represents deflection of the thromboelastography probe. The R time is also assessed by tests such as the prothrombin time (PT), the activated partial thromboplastin time (aPTT), and the activated clotting time (ACT). D-dimer is used to assess fibrinolysis.

    Adapted from Singh AD, Shalimar. Use of blood products and drugs before procedures in patients with cirrhosis. Clin Liver Dis (Hoboken) 2020; 16(4):153–157. doi:10.1002/cld.906, reference 36.

  • Figure 4
    Figure 4

    Results of thromboelastography in various conditions.

Tables

  • TABLE 1

    Bleeding risk associated with invasive procedures

    High-risk procedures
    All major surgeries (cardiac, intra-abdominal, orthopedic, brain, spine)
    Intracranial pressure catheter insertion
    Endoscopy: large polypectomy with endoscopic mucosal resection or submucosal resection
    Moderate-risk procedures
    Lumbar puncture
    Percutaneous or transjugular liver biopsy
    Transarterial or percutaneous therapies for hepatocellular carcinoma
    Transjugular intrahepatic portosystemic shunt
    Endoscopy for percutaneous gastrostomy placement, biliary sphincterotomy
    Low-risk procedures
    Paracentesis
    Thoracocentesis
    Dental extraction
    Cardiac catheterization
    Central line placement
    Endoscopy for diagnosis, variceal band ligation, uncomplicated polypectomy

    • Note: Risk is calculated based on relative vascularity, expected vascular breech, and potential clinical consequences. Risk should always be defined by the clinician performing the procedure.

    • Adapted from Intagliata NM, Argo CK, Stine JG, et al. Concepts and controversies in haemostasis and thrombosis associated with liver disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118(8):1491–1506. doi:10.1055/s-0038-1666861, reference 55.

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