Should we be concerned about coagulation in the treatment of acute variceal hemorrhage?

Chronic liver disease (cirrhosis) is characterized by a defective synthesis of coagulation factors and by thrombocytopenia. These abnormalities have qualified cirrhosis as the prototype of the acquired coagulopathies. As a consequence patients were (and are) screened with traditional hemostasis tests and those with abnormal values are infused with coagulation factor concentrates, fresh frozen plasma, or platelets in order to correct the abnormal test values before surgery or invasive procedures. However, recent evidence from the literature showed that hemostasis in cirrhosis is rebalanced owing to the concomitant reduction of both pro- and anticoagulant factors as well as increased levels of von Willebrand factor. Indeed, coagulation assessed as thrombin generation in plasma is normal or even increased, and platelet function is somewhat restored. These observations point to conclude that the bleeding events observed in patient with cirrhosis are likely due to the underlying conditions associated with cirrhosis (i.e., portal hypertension, bacterial infections, endothelial dysfunction, and renal failure) rather than to the hemostasis derangement. Therefore, the common practice of screening patients with traditional coagulation tests and the correction of their abnormalities should be reconsidered.