Managing coagulation abnormalities, bleeding, and thrombosis in patients with cirrhosis

Abstract

Cirrhosis is associated with a narrow balance between procoagulant and anticoagulant factors that may lead to potentially serious complications. Interpretation of laboratory tests, prevention of bleeding during invasive procedures, and use of anticoagulant drugs for the prevention and treatment of thromboembolism are often challenging. After reviewing the most contemporary literature, we hereby provide guidance to navigate the evidence and support clinical decisions. Based on current knowledge, prothrombin time and activated partial thromboplastin time do not accurately describe hemostasis in patients with cirrhosis and should not be used to predict bleeding. Rather, a careful assessment of patient and procedure-related variables better helps to identify patients at increased bleeding risk. Because procedure-related bleedings are uncommon in patients with cirrhosis, the use of prophylactic strategies is seldom necessary in daily practice. In case of perioperative bleeding, viscoelastometry may be useful to drive decisions on the use of transfusion products. Portal vein thrombosis is a common complication in patients with cirrhosis and requires a timely start of anticoagulant treatment, especially when vessel obstruction exceeds 50% of the lumen diameter. Treatment should be continued for at least 6 months. The direct oral anticoagulants are increasingly used in this setting, representing a valid alternative to the heparins and vitamin K antagonists. Atrial fibrillation in cirrhosis is associated with a high risk of ischemic stroke and treatment-related major bleeding. The benefit of anticoagulants is supported by the results of observational studies, and the direct oral anticoagulants are suggested as the first line of treatment also for this population.