Center for the Study of Hemostasis and Coagulation in Liver Disease, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA.
Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
J Thromb Haemost. 2021 Jul;19(7):1644-1652. doi: 10.1111/jth.15364. Epub 2021 Jun 6.
Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure-related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post-procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.
肝硬化患者的止血系统常发生复杂改变。尽管肝硬化患者常规的止血功能诊断测试（血小板计数、凝血酶原时间、纤维蛋白原水平）提示存在出血倾向，但现在已广泛接受这些测试并不能反映该人群的止血能力。相反，肝硬化患者的止血系统似乎存在再平衡，具有高凝因素。因此，正如最近的临床指南文件所概述的那样，不建议纠正常规止血实验室值，例如通过新鲜冷冻血浆或血小板浓缩物，以避免自发性或与操作相关的出血。然而，对于正在出血的肝硬化患者的管理，几乎没有可用的指导。在这里，我们介绍了三种常见的出血情况，即静脉曲张出血、术后出血和重症肝硬化患者出血，并提出了具体的管理建议。由于肝硬化患者通常具有足够的止血能力，并且出血并发症可能与止血失败无关，因此，在存在明显异常血小板计数和/或凝血酶原时间的情况下，促凝治疗并不是肝硬化出血患者的一线治疗方法。我们为肝硬化出血患者采用限制促凝治疗方法提供了一个理由。
