AGA Management of Coagulation Disorders in Patients With Cirrhosis Guideline Summary

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 )

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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) )

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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.

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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.

Management of Coagulation Disorders in Patients With Cirrhosis