I have a female patient with decompensated liver cirrhosis attributed to hepatitis C virus; presented with right leg deep vein thrombosis including popliteal and iliac veins, her INR was 1.4. Can I give this lady heparin and then warfarin?
I would consider deep venous thrombosis of the iliac veins a more serious condition in short term as the cirrhosis. So I would give low molecular weight heparins and after 2 days warfarin to aim an INR of 2. And check for pelvic masses (it's an unusual combination of diseases - it could be a third one to make the link).
Salve.
Dr Ali, but if the platelets are low, would you use low molecular weight heparin?
Patients like this one are usually excluded from clinical trials, so we can manage them only with a careful assessment and courage, and patient consent. I would take into account the Child-Pugh stage, and the presence of esophageal varices, as already stated by dr. Latif. If the life expectancy is very short and she suffered from previous episodes of bleeding, I would probably prefer a vena cava filter to prevent pulmonary embolism. Otherwise I would treat her as usual, optimizing portal hypertension treatment, including beta blockers as propanolol or carvedilol. Endoscopic variceal ligation should be considered. Obviously, a strict surveillance and follow-up is needed, and I suggest to stop the treatment as soon as possible (i.e., three months if the DVT appeared to be provoked, or six months otherwise).
If there no history of bleeding, then I would recommend anticoagulation. The challenge is interpretation of the INR in a patient with concomitant coagulopathy, which has not been adequately studies. For that reason, you might consider LMWH as mentioned above. I would avoid a filter; it can be placed safely, but anticoagulation is likely to be more efficacious.
cirrhosis, deep vein thrombosis of the iliac arteries in patients with esophageal varices? the dosage AT3? bleeding time? proof of the lace? AT3 if below normal, low molecular weight heparin is after checking creatinine or fondaparinux sodico.e 'an obligation evaluate caval umbrella. many cirrhosis are accompanied by chronic intravascular coagulation usually trim and' procoagulant for this reason make trombosi.v.antonini
We must balance between risk and benefit and use the adequate assays.
Cirrhotic patients (like hemophiliacs) can have congenital or adquired thrombosis factor.
Antivitamin K (AVK) anticoagulants will decrease procoagulant factors (II, VII, IX and X) but also decrease anticoagulants factors (prot S and C)!
We must remenber that INR was designed only to monitor oral AVK treatment, NOT to predict bleeding risk neither nornal nor cirrhotic patients.
We ussualy anticoagulant them, but with closer controls, and monitoring platelets level (but we must have in mind that sometimes platelest production is maintained, and the main cause could be "sequestration" by hypersplenism)!!
Yes you can and need to anticoaugulate. The INR is not in this case an indicator of "autoanticoagulation". The liver disease also leads to lower Protein C and S levels which will cause a tendency for thrombosis. Be sure that an upper endoscopy does not show large varcies or a high risk to bleed. If not begin anticoagulation (coumadin is safe with goal INR about 2. If varices are seen banding can be done to eradication then begin anticoagulation (likely would need temporary IVC filter in this case)
The problem in this case is, that a prolonged INR in patients with severe hepativc failure does not indicate a hemophilic state. Patients with chronic hepatic failure (due to cirrhosis) and a prolonged INR actually do suffer from a latent prothrombotic state caused by low Prot C & low Prot S. levels (and DVTs in such patients do frequently occure) . Of course this patient definitively needs anticoagulation but how this is done is a matter of eminence - not of evidence. Coumadins may increase the problem of prothrombosis for low Prot. C & Prot S levels. To my opinion careful anticoagulation with a renally cleared NOAC could therefore be a matter of choice (Dabigatran 2x75mg or 2x110mg e.g.). In any case D-dimer should also be monitored since as long as D-dimers remain high, the anticoagulation will not be adequate to prevent rethrombosis.
The problems with vena cava filters is, that they frequently occlude (as aconsequence to their function) causing venous obstruction in both lower limbs. They even can cause pulmonary embolism from the filter as the source. Hence, the need for anticoagulation is not really avoided with filters.
I must stress: this advice is eminence based (though eminence from an experienced hemostaseologist). In Germany one would call this "individueller Heilversuch!"
Great explanation!
Cirrotic patients usually have thrombosis!
Both thrombotic and antithrombotic synthesis is impaired!
Cava Filters must be used only in case of absolute anticoagulation contraindication!
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