Patients with cirrhosis are fairly common in the inpatient setting, and often the desire to know the patients coagulability during their stay arises. But how does one assess such for a patient with cirrhosis? Can we check a PT/INR? What about a PTT? Surely between those tests we can determine the patient’s coagulability, right? Well, no. These tests cannot give an accurate picture of the coagulability of a patient with cirrhosis, and this article will seek to provide a rationale for this claim, as well as present an alternative way to assess for coagulability in those with cirrhosis. 

So why can’t we utilize PT/PTT/INR in such patients? Well, that comes down to understanding what the liver produces in the way of proteins that influence coagulation. It certainly produces a lot of pro-coagulant products such as coagulation factors, prothrombin, and fibrinogen; however, it also produces anticoagulants as well–such as protein C/S, and antithrombin 3. And in this, lies the problem. Though we are able to gain insight into the pro-coagulant factors with tests such as PT/PTT/INR, we are only able to see one side of the coagulation equation. So while a patient’s INR may be 5, they may still be in a procoagulant state because of an elevated capacity to produce thrombin and fibrinogen, or because of a significant drop in the patient’s protein C/S concentrations. 

So we have said that standard testing for coagulability may not be sufficient for those with cirrhosis, so how do we assess this? Thromboelastography, or TEG for short. TEG allows for the determination of how well blood can make a hemostatic plug. It is the only way in which patients with cirrhosis can have their coagulability fully assessed. 

Sources:

Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med. 2018 Sep;19(5):863-871. doi: 10.5811/westjem.2018.7.37893. Epub 2018 Aug 8. PMID: 30202500; PMCID: PMC6123093.

Islam R, Kundu S, Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Sange I. Cirrhosis and Coagulopathy: Mechanisms of Hemostasis Changes in Liver Failure and Their Management. Cureus. 2022 Apr 3;14(4):e23785. doi: 10.7759/cureus.23785. PMID: 35518552; PMCID: PMC9063731.

Stravitz RT. Potential applications of thromboelastography in patients with acute and chronic liver disease. Gastroenterol Hepatol (N Y). 2012 Aug;8(8):513-20. PMID: 23293564; PMCID: PMC3533209.

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