Management of Coagulation Disorders in Patients With Cirrhosis
Publication Date: September 24, 2021
Last Updated: October 5, 2022
Diagnosis
Testing Strategy
Visco-elastic Testing (VET)
In patients with stable cirrhosis undergoing common gastrointestinal procedures, the AGA makes no recommendation regarding VET before procedures to predict bleeding risk. ( Evidence Gap , No recommendation )
612
PLT and PT/INR
In patients with stable cirrhosis (with known baseline abnormal coagulation parameters) undergoing common gastrointestinal procedures (e.g., paracentesis, thoracentesis, variceal banding, colonic polypectomy, endoscopic retrograde cholangiopancreatography [ERCP], and liver biopsy), the AGA suggests against the use of extensive preprocedural testing, including repeated measurements of PT/INR or PLT count. ( Very Low , Conditional (weak) )
612
Portal Vein Thrombosis (PVT) Screening
In patients with cirrhosis, the AGA suggests against routine screening for PVT. ( Very Low , Conditional (weak) )
Comment: Patients who put a high value on the uncertain benefits of PVT screening and a low value on the potential downsides and harms related to treatment would reasonably select screening. This does not apply to patients who are listed for liver transplantation.
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Treatment
Preprocedure Prophylaxis
PLT and/or Fresh Frozen Plasma (FFP)
In patients with stable cirrhosis undergoing common gastrointestinal procedures (e.g., paracentesis, thoracentesis, variceal banding, colonic polypectomy, ERCP, and liver biopsy), the AGA suggests against the routine use of blood products (e.g., FFP and PLTs) for bleeding prophylaxis. ( Very Low , Conditional (weak) )
Comment: This recommendation applies to the majority of patients with stable cirrhosis who usually do not have severe thrombocytopenia or severe coagulopathy. In patients with severe derangements in coagulation or thrombocytopenia undergoing a procedure that is high risk for bleeding, decisions about prophylactic blood transfusions should include discussions about potential benefits and risks (including transfusion reactions and delay of procedure) in consultation with a hematologist.
612
Thrombopoietin receptor agonist (TPO-Ras)
In patients with thrombocytopenia and stable cirrhosis undergoing common procedures (and in particular, “low-risk” procedures), the AGA suggests against the routine use of TPO-RAs for bleeding prophylaxis. ( Very Low , Conditional (weak) )
Comment: Patients who place a high value on the uncertain reduction of procedural bleeding events and a low value on the increased risk for PVT can reasonably select a TPO-RA.
612
Venous Thromboembolism (VTE) Prophylaxis With Anticoagulation
In hospitalized patients with cirrhosis and who otherwise meet standard guidelines for the use of VTE prophylaxis, the AGA suggests standard anticoagulation prophylaxis over no anticoagulation. ( Very Low , Conditional (weak) )
612
Acute or Subacute Non-tumoral Portal Vein Thrombosis
In patients with cirrhosis and acute or subacute nontumoral PVT, the AGA suggests using anticoagulation over no anticoagulation for treatment of PVT. ( Very Low , Conditional (weak) )
Comment: Patients who put higher value on the bleeding risk on anticoagulation and a lower value on the uncertain benefits of anticoagulation would reasonably choose no anticoagulation.
612
Atrial Fibrillation
In patients with cirrhosis and atrial fibrillation with an indication for anticoagulation, the AGA suggests using anticoagulation over no anticoagulation. ( Very Low , Conditional (weak) )
Comment: Patients, particularly those with more advanced cirrhosis (Child-Turcotte-Pugh class C) and/or low CHA2DS2-VASC scores who put high value on avoiding the bleeding risk on anticoagulation and lower value on the stroke reduction could reasonably choose no anticoagulation.
612
Recommendation Grading
Overview
Title
Management of Coagulation Disorders in Patients With Cirrhosis
Authoring Organization
American Gastroenterological Association
Publication Month/Year
September 24, 2021
Last Updated Month/Year
January 24, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
To provide recommendations for pertinent clinically relevant questions related to hemostasis of bleeding, as well as prevention and treatment of thrombosis in patients with cirrhosis
Target Patient Population
Patients with cirrhosis
Target Provider Population
Primary care providers, gastroenterologists, hepatologists
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D000925 - Anticoagulants, D001778 - Blood Coagulation Disorders, D008103 - Liver Cirrhosis
Keywords
cirrhosis, coagulation, bleeding outcomes, coagulopathy, bleeding risk assessment, anticoagulant therapies
Source Citation
O’Shea RS, Davitkov P, Ko CW, et al. AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis. Gastroenterology. 2021;161(5):1615-1627. doi: 10.1053/j.gastro.2021.08.015.