Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 18, 2015; 7(14): 1818-1827
Published online Jul 18, 2015. doi: 10.4254/wjh.v7.i14.1818
Spontaneous bleeding or thrombosis in cirrhosis: What should be feared the most?
Kryssia Isabel Rodríguez-Castro, Alessandro Antonello, Alberto Ferrarese
Kryssia Isabel Rodríguez-Castro, Alberto Ferrarese, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
Alessandro Antonello, Veneto Oncological Institute (IOV-IRCCS), 35128 Padua, Italy
Author contributions: All the authors equally contributed to this work.
Conflict-of-interest statement: All Authors declare they have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Kryssia Isabel Rodríguez-Castro, MD, PhD, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy. kryssiarodriguez@yahoo.com
Telephone: +39-33-36167592 Fax: +39-49-8218727
Received: January 29, 2015
Peer-review started: March 2, 2015
First decision: March 6, 2015
Revised: March 30, 2015
Accepted: May 5, 2015
Article in press: May 6, 2015
Published online: July 18, 2015

The more modern and accurate concept of a rebalanced hemostatic status in cirrhosis is slowly replacing the traditional belief of patients with cirrhosis being “auto-anticoagulated”, prone only to bleeding complications, and protected from thrombotic events. With greater attention to clinical thrombotic events, their impact on the natural history of cirrhosis, and with the emergence and increased use of point-of-care and global assays, it is now understood that cirrhosis results in profound hemostatic alterations that can lead to thrombosis as well as to bleeding complications. Although many clinical decisions are still based on traditional coagulation parameters such as prothrombin (PT), PT, and international normalized ratio, it is increasingly recognized that these tests do not adequately predict the risk of bleeding, nor they should guide pre-emptive interventions. Moreover, altered coagulation tests should not be considered as a contraindication to the use of anticoagulation, although this therapeutic or prophylactic approach is not at present routinely undertaken. Gastroesophageal variceal bleeding continues to be one of the most feared and deadly complications of cirrhosis and portal hypertension, but great progresses have been made in prevention and treatment strategies. Other bleeding sites that are frequently part of end-stage liver disease are similar to clinical manifestations of thrombocytopenia, with gum bleeding and epistaxis being very common but fortunately only rarely a cause of life-threatening bleeding. On the contrary, manifestations of coagulation factor deficiencies like soft tissue bleeding and hemartrosis are rare in patients with cirrhosis. As far as thrombotic complications are concerned, portal vein thrombosis is the most common event in patients with cirrhosis, but venous thromboembolism is not infrequent, and results in important morbidity and mortality in patients with cirrhosis, especially those with decompensated disease. Future studies and the more widespread use of point-of-care tests in evaluating hemostasis will aid the clinician in decision making when facing the patient with bleeding or with thrombotic complications, with both ends of a continuum being potentially fatal.

Keywords: Bleeding, Hemorrhage, Thromboembolism, Portal vein thrombosis, Coagulation, Cirrhosis

Core tip: The two-faced, dynamic, and fragile hemostatic and coagulation system of patients with cirrhosis is of increasing interest. Thrombotic complications, and not only the well-known bleeding complications such as gastroesophageal bleeding, are now recognized complications of cirrhosis. Whether confined to the portal vein, due to venous stasis but also to other yet poorly characterized local as well as systemic factors, or in the presence venous thromboembolism, these complications warrant prevention and treatment with anticoagulation. Future clinical studies, as well as the broader implementation of point-of-care instruments and results from studies using global coagulation assays will outline the best strategies, tailored to each patient according to the severity of liver disease and the particular hemostatic alterations present at a given timepoint.