hi! I would consider after an accurate study of the genetic factor v I factor II II the simple observation of peripheral blood counts plats search schistocytes and LDH AT3.La correction of coagulation? fresh frozen plasma . if you do not agree you answer me!

Thrombosis and bleeding occuring in the same patient is indicative of disseminated intravascular coagulation or DIC. First determine the cause of DIC. It could be gram negative septicemia , malignancy etc. Treatment of DIC is treatment of the underlying cause. Factor V Leiden mutation and prothrombin gene 20210 mutation may be precipitating causes of thrombosis. In DIC due to the underlying causes there could be elevation in the cytokine levels. The cytokine can activate thrombosis and fibrinolysis simultaneously causes thrombosis and bleeding simultaneously.

It is important to assess the individual patient and take into consideration the individual risk of life threatening bleeding and thrombosis. In patient with hemoptysis and pulmonary infarction the full dose anticoagulant therapy (LMWH followed by warfarin) is indicated, because the pulmonary embolism is the cause of secondary bleeding. In the case of melena and subsequent acute limb ischemia, the upper GIT endoscopy and local measure to stop the bleeding is essential and concomitantly the percutaneous intervention aimed to restoration of the blood flow in the limb arteries can be carried out. Subsequently, antiplatelet therapy could be a good choice. Generally, in the case of contemporary bleeding and thrombosis, the local hemostatic measures (if possible) and systemic antithrombotic therapy can be considered.

In addition it is also important to think about elderly patients with hemophilia with arterial thrombosis (e.g. myocardial infarction) as a result of atherosclerosis and ageing, or DVT as a result of concomitant thrombophilia. In these cases the coagulation factor replacement along with antiplatelet and/or anticoagulation drugs are required.

Dear Josè, thank you for posting these very interesting topics, that are largely undercovered in medical literature. When facing non massive hemoptysis in pulmonary embolism, I usually continue full dose LMWH. Very rarely the bleeding is life-treathening; in such cases I think that the patient should be managed accordingly, with antithrombotic withdrawal and possibly reversal, best supportive therapy (including transfer in intensive care unit and broncoscopy),

and probably - in the case of acute lower limb deep vein thrombosis - placing of an inferior vena cava filter, although the evidence is lacking. I've not direct experience in managing patients with upper gastrointestinal (GI) hemorrhage and acute limb ischemia. The question regarding GI bleeding during splanchnic thrombosis deserves a more detailed approach: which kind of bleeding? variceal or from ulcers or pre-esistent conditions at risk of bleeding? Finally, the balance between bleeding and thrombotic risk is a very challenging one, and must always be tailored to the patient. However, the late consequences of thrombosis are usually more invalidant than those of bleeding, so I'm prone to undertake every effort to treat thromboses if it is possible to face the bleeding event.

A bit late to the party here but there are a couple of resources I can share that might be helpful, regarding PVT bleed management (http://emcision-2204653.hs-sites.com/rfa-for-interventional-radiologists-0) and also some upper GI bleed approaches from the interventional radiologist POV (https://youtu.be/shI5i3j2Obs)