Ep 149 Liver Emergencies: Thrombosis and Bleeding, Portal Vein Thrombosis, SBP, Paracentesis Tips and Tricks

This is part 2 of our podcast series on liver disease for the ED doc with Walter Himmel and Brian Steinhart. We clear up the confusing balance between thrombosis and bleeding in liver patients, the elusive diagnosis of portal vein thrombosis, spontaneous bacterial peritonitis diagnosis and treatment and some tips and tricks on paracentesis. We answer questions such as: How is it that liver patients are at increased risk for both thrombosis and bleeding? How should we interpret the INR of liver patients in the setting of thrombosis or bleeding? Should a liver patient with an elevated INR be placed on an anticoagulant for portal vein thrombosis or pulmonary embolism? Is there a role for TXA in the bleeding liver patient? Why were PCCs rarely indicated in the liver patient in the past, and now being reconsidered? Do you need to obtain an INR before performing a paracentesis? At what platelet count is it safe to perform a paracentesis? What are the indications for giving albumin after paracentesis? for spontaneous bacterial peritonitis? and many more... Podcast production, sound design & editing by Anton Helman. Voice editing by Raymond Cho. Written Summary and blog post by Anton Helman  & Jennifer He, November, 2020 Cite this podcast as: Helman, A. Himmel, W, Steinhart, B. Episode 149 Liver Emergencies: Thrombosis and Bleeding, Portal Vein Thrombosis, SBP, Paracentesis Tips and Tricks. Emergency Medicine Cases. November, 2020. https://emergencymedicinecases.com/liver-emergencies-thrombosis-bleeding-portal-vein-thrombosis-sbp-paracentesis. Accessed [date] For part 1 of this series on Liver Emergencies go to Episode 148 Liver Emergencies: Acute Liver Failure, Hepatic Encephalopathy, Hepatorenal Syndrome, Liver Test Interpretation & Drugs to Avoid Liver patients are at higher risk of clotting than of bleeding There is a complex imbalance of coagulation factors in the liver patient that is essential to understand for effective management of thrombotic and hemorrhagic events. In general, patients with liver disease are more likely to develop thrombotic disease than they are bleeding diathesis, even if the INR is elevated. Increased risk of thrombosis: patients with cirrhosis may have decreased protein S and C more so than a reduction in Factors 2, 7, 9, 10 and this would favor thrombosis, rather than bleeding. Pitfall: a common pitfall is assuming that a liver patient with an elevated INR is protected from thrombotic events. An elevated INR level does not imply that the patient is protected from pulmonary embolism or portal vein thrombosis. Hypoalbuminemia can be considered a risk factor for thrombosis risk in liver patients A potential predictor of venous thromboembolism in a cirrhotic patient (assumed to be “auto-anticoagulated” based on an elevated INR value) is serum albumin. It is hypothesized that lower serum albumin concentration is a surrogate for decreased protein synthesis by the liver and thus decreased production of endogenous anticoagulant factors such as Protein C and S. In short, if the albumin is low, the patient may be at increased risk of thromboembolic events. Treatment of thrombotic liver disease: cirrhotic vs non-cirrhotic Treatment of thrombotic liver disease varies with the presence or absence of cirrhosis. Cirrhosis increases the risk of catastrophic bleeding from esophageal or gastric varices if the patient is anticoagulated. Patients with cirrhosis who require anticoagulation need careful evaluation with endoscopy for varices and these varices are best definitively treated wi...