Insights into cirrhotic bleeding of liver and how to stop it
In this video, Dr. Seheult of MedCram discusses how to stop bleeding in cirrhosis. Cirrhosis is an end stage liver disease condition. It can be caused by a number of things that contribute to inflammation in the liver such as hepatitis, alcohol and even non-alcoholic steatohepatitis otherwise known as fatty liver.
Dr. Seheult reports he had a particular case while he was doing his ICU duties in the hospital where he had a liver patient that was bleeding and he could not get the bleeding to stop with traditional means. He found a reference in the Internet Book of Critical Care that taught him something new.
This case involves a young male with alcoholic cirrhosis who was going into alcohol withdrawal. His liver disease was advanced and he had ascites (fluid that goes into the belly from the liver) and causing abdominal distention. In this particular case, the ascitic fluid had traveled above the diaphragm (muscle separating the lung cavity from abdominal cavity) and gone into the space around the lung causing a pleural effusion. The patient required being intubated and being put on the ventilator.
What is involved in a paracentesis?
Part of the work up for these patients involves making sure that the ascites fluid is not infected and this requires a procedure called a paracentesis, where a needle is inserted into the abdominal cavity to remove fluid to relieve the distention and send it for studies. However, there are always risks with paracentesis and these include infection and bleeding. There are blood vessels that run through the abdominal wall and as the needle is going through, it is possible to nick one of those vessels. In normal circulation, blood is supposed to come up through the abdomen and go to the liver and then to the heart. In liver cirrhosis, the liver itself becomes almost impassable and what happens is that blood tries to go around the liver and causes bulging in other vessels such as in esophageal varices, hemorrhoids, etc. The vessels in the abdominal area can also become engorged. Most of the time paracentesis are uneventful.
In this patient’s case, it appeared the paracentesis went through without issues, but it was noted the next day that the patient’s hemoglobin had dropped by about 2 points. It went from a hemoglobin of 7 down to a hemoglobin of 5 and it continued to drop again despite repeated blood transfusions. An ultrasound of the abdominal wall showed pockets which were suspected to be coagulated blood. It was felt that the patient was most likely bleeding from the procedure.
How does blood clotting work in liver cirrhosis?
How do you stop bleeding in liver disease? Normally within a blood vessel, if there is bleeding, you want to get the formation of a blood clot. This will involve plasma which comes from outside the blood vessel system from the liver and utilizes vitamin K to produce factors that are part of plasma. This is measured by the INR. Ideally for bleeding purposes, you want to have an INR less than 1.5. The higher the INR, the greater the likelihood the bleeding will be more severe. It implies there isn’t enough plasma and blood clots are less likely to occur. Another thing needed for clotting are platelets. These will contribute to blood clots as they will be the first foundational layer to form the clot. The other major ingredient is fibrinogen. The problem is that if that is all we had then the body would be clotting off all of the time. To counter this, the body makes a chemical called TPA that is secreted from the blood vessel endothelium (inner covering of the blood vessel) and this stimulates this blood clot to become dissolved. You can order a d-dimer test and if this is elevated then it signifies there are products of clot breakdown. This is normally a balance. Normally TPA is broken down by the liver.
What is accelerated intravascular coagulation and fibrinolysis?
In this patient with liver issues, however, the TPA was not being broken down and was hanging around longer leading to more clot breakdown. This process is known as accelerated intravascular coagulation and fibrinolysis. The fibrinogen in this process starts to decrease due to being utilized in the making of blood clots only to be dissolved by the TPA. In this patient with liver failure, his TPA levels were increasing and fibrinogen levels were decreasing despite the fact that plasma had been given to this patient and that he had adequate platelets. A fibrinogen level was ordered and came back less than 100 confirming that the patient was in accelerated intravascular coagulation and fibrinolysis. Dr. Seheult states he ordered a pack of cryoprecipitate which has lots of fibrinogen.
How does TPA affect bleeding in liver cirrhosis?
This doesn’t solve the entire problem however, as the real problem is that the TPA is not being stopped from dissolving the clots. What was needed was a medication to stop the effects of TPA and in this case there are two possibilities for this. Tranexamic acid and aminocaproic acid are substances that both block TPA. In this particular case, tranexamic acid was used and as soon as this was infused, the patient’s bleeding stopped. His fibrinogen levels were followed and were maintained above 100 and no further replacements were needed. The d-dimer levels came down also.
The moral of the story is that if there is bleeding in a liver patient with cirrhosis that you are treating, get a fibrinogen level. If it is low, the patient may be experiencing accelerated intravascular coagulation and fibrinolysis. Side effects of tranexamic acid include seizure.
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