Management of Coagulation Disorders in Patients With Cirrhosis

Publication Date: September 23, 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 )
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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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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.
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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.
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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) )
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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.
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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.
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Recommendation Grading

Overview

Title

Management of Coagulation Disorders in Patients With Cirrhosis

Authoring Organization

American Gastroenterological Association

Publication Month/Year

September 23, 2021

Last Updated Month/Year

October 3, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline aims 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. Recognizing that prediction of bleeding or thrombotic events in this population is challenging, a detailed understanding of the current evidence in this field is vital to deliver the safest and most effective care to this vulnerable patient population.

Target Patient Population

Patients with cirrhosis

Target Provider Population

Primary care providers, gastroenterologists, hepatologists

PICO Questions

  1. What testing strategy for bleeding risk assessment is most beneficial for patients with cirrhosis?

  2. Does preprocedure prophylaxis to correct coagulation parameters and/or PLT level reduce the risk of bleeding in patients with cirrhosis?

  3. Is venous thromboembolism (VTE) prophylaxis indicated in hospitalized patients with cirrhosis?

  4. Should patients with cirrhosis be screened for nontumoral portal vein thrombosis (PVT)?

  5. Does preprocedure prophylaxis (ie, using blood product transfusion or TPO-RAs) to correct coagulation parameters and/or PLT level reduce the risk of bleeding in patients with cirrhosis?

  6. Should visco-elastic testing (VET) be performed in patients with cirrhosis before procedures?

  7. Should PLT and PT/INR testing be done before procedures to predict procedure-related bleeding?

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.

Supplemental Methodology Resources

Technical Review