Prelipcean Cristina Cijevschi, Fierbinteanu-Braticevici Carmen, Drug V L, Lăcătuşu Cristina, Mihai B, Mihai Cătălina
U.M.F. "Gr. T. Popa" Iaşi, Institutul de Gastroenterologie şi Hepatologie Iaşi.
Rev Med Chir Soc Med Nat Iasi. 2011 Jul-Sep;115(3):678-85.
Abnormal hemostasis tests and bleeding are often associated in liver cirrhosis. In these patients the balance between hypo- and hypercoagulation status is more fragile than in healthy people. In the hemostatic abnormalities associated with chronic liver disease are two main chategory factors: favoring hemorrage and favoring thrombosis. The main factors that favoring hemorrage are: low platelet count, impaired platelet function, decreased levels coagulation factors (II, V, VII, IX, X, XI), quantitative and qualitative abnormalities of fibrinogen, vitamin K defiency, low levels of trombin activable fibrinolisis inhibitor, activat plasminogenic tisular. The factors favoring thrombosis are elevated levels of factors VIII and von Willebrand, decreased levels of protein C, protein S, antithrombin, decreased levels of plasminogen. Traditionally it was thought that arterial and venous thrombosis is rare events in cirrhotic patients but recent studies have indicated that thrombotic complications can paradoxically occur even if clinically an increased risk of hemorrhage is considered. Treatment of venous thrombosis in patients with cirrhosis using routine anticoagulation with heparin and vitamin K antagonists has been described but with a high level of bleeding complications. So, based on the limited data available, AASLD guidelines stated no recommendations for or against the use of anticoagulation in cirrhotic patients with portal thrombosis. Although abnormal hemostasis tests and bleeding are often associated in patients with chronic liver disease it is a relatively poor correlation between hemorrhagic risk and routine diagnostic tests of hemostasis. Management of bleeding complications in liver cirrhosis varies and no general guidelines are available. The main therapeutic strategies are: red cell concentrate, plasma, platelet concentrate, recombinant factor VIIa, factor concentrates, desmopressin, antifibrynolitic agents, thrombopoietin receptor agonists, antibiotics. Clinical studies examining safety and efficacy of the various products for the different bleedeing or trombotic complications of liver cirrhosis need to be initiaded.
异常止血检查与出血在肝硬化患者中常相关联。在这些患者中，低凝和高凝状态之间的平衡比健康人更为脆弱。与慢性肝病相关的止血异常主要有两类因素：促出血因素和促血栓形成因素。促出血的主要因素有：血小板计数低、血小板功能受损、凝血因子（II、V、VII、IX、X、XI）水平降低、纤维蛋白原的定量和定性异常、维生素K缺乏、凝血酶激活的纤维蛋白溶解抑制剂水平低、组织型纤溶酶原激活物。促血栓形成的因素有：因子VIII和血管性血友病因子水平升高、蛋白C、蛋白S、抗凝血酶水平降低、纤溶酶原水平降低。传统上认为动脉和静脉血栓形成在肝硬化患者中是罕见事件，但最近的研究表明，即使临床上认为出血风险增加，血栓形成并发症也可能反常地发生。已描述了使用肝素和维生素K拮抗剂进行常规抗凝治疗肝硬化患者静脉血栓形成的情况，但出血并发症发生率较高。因此，基于有限的现有数据，美国肝病研究学会（AASLD）指南未就肝硬化合并门静脉血栓形成患者使用抗凝治疗给出支持或反对的建议。尽管异常止血检查与出血在慢性肝病患者中常相关联，但出血风险与常规止血诊断检查之间的相关性相对较差。肝硬化出血并发症的管理各不相同，且没有通用指南。主要治疗策略有：红细胞浓缩液、血浆、血小板浓缩液、重组凝血因子VIIa、凝血因子浓缩剂、去氨加压素、抗纤维蛋白溶解剂、血小板生成素受体激动剂、抗生素。需要开展临床研究，以检验各种产品对肝硬化不同出血或血栓形成并发症的安全性和有效性。
