Comment to “Bleeding and thrombosis in cirrhotic patients: What really matters?”

Abstract

Ferro and colleagues recently reviewed data on bleeding and thrombosis in cirrhotic patients [ [1] Ferro D. Angelico F. Caldwell S.H. et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Digestive and Liver Disease. 2012; 44: 275-279 Abstract Full Text Full Text PDF Scopus (35) Google Scholar ]. The authors carefully examined the paradoxical situation of haemostasis in cirrhotics, mainly depending on clotting impairment due to both platelets and coagulation factors reduction, on one side, and, on the other, a hypercoagulation status secondary to anticoagulant factors (protein C and S) deficit. As a result, cirrhotics are predisposed to both haemorrhagic events – especially in the gastrointestinal tract – and thrombosis – particularly in the portal vein [ [1] Ferro D. Angelico F. Caldwell S.H. et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Digestive and Liver Disease. 2012; 44: 275-279 Abstract Full Text Full Text PDF Scopus (35) Google Scholar ]. As far as the bleeding related to invasive procedures, the Authors evaluated the haemorrhage probability following liver biopsy, central venous cannulation procedure, and paracentesis. Overall, it has been reported that post-procedure bleeding rate is acceptably low (<2.5%) in those patients with international normalized ratio (INR) <1.5 and platelet count >50,000–60,000/mm3 [ [1] Ferro D. Angelico F. Caldwell S.H. et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Digestive and Liver Disease. 2012; 44: 275-279 Abstract Full Text Full Text PDF Scopus (35) Google Scholar ]. We would suggest that discussing data on bleeding probability following gastric biopsies in cirrhotics could be a another clinically relevant issue. Both peptic ulcers (gastric and duodenal) prevalence and gastric cancer incidence are increased in cirrhotics as compared to matched controls [ 2 Zullo A. Rinaldi V. Meddi P. et al. Helicobacter pylori infection in dyspeptic cirrhotic patients. Hepato-Gastroenterology. 1999; 46: 395-400 PubMed Google Scholar , 3 Zullo A. Romiti A. Tomao S. et al. Gastric cancer prevalence in patients with liver cirrhosis. European Journal of Cancer Prevention. 2003; 12: 179-182 Crossref PubMed Scopus (31) Google Scholar ]. Indeed, it has been found that Helicobacter pylori infection causes peptic ulcer in cirrhotics more frequently than controls [ [4] Zullo A. Hassan C. Morini S. Helicobacter pylori infection in patients with liver cirrhosis: facts and fictions. Digestive and Liver Disease. 2003; 35: 197-205 Abstract Full Text Full Text PDF Scopus (32) Google Scholar ], and its eradication is recommended to prevent non-variceal gastrointestinal bleeding in these patients [ [5] Zullo A. Cristofari F. Hassan C. H. pylori should be eradicated in chronic liver disease patients with peptic ulcer. Digestive and Liver Disease. 2009; 41: 141-142 Abstract Full Text Full Text PDF Scopus (2) Google Scholar ]. Consequently, to take biopsies during upper endoscopy in cirrhotic patients is not a rare event in clinical practice. In past, we focused our research on H. pylori-related gastroduodenal diseases in patients with live cirrhosis. In Table 1, we provided data of our studies regarding 587 cirrhotics who underwent upper endoscopy with biopsies. As shown, we performed multiple gastric biopsies when platelets count was >45,000–50,000/mm3 and the prothrombin activity percentage >45–50% (such a parameter was usually used instead of INR in the past). No case of manifest bleeding was observed at follow-up. Therefore, the suggested values of both platelets (>50,000/mm3) and INR (<1.5) could be considered a safe cut-off also to perform gastric biopsies in these patients. Our finding could add some information on the post-procedure bleeding risk in cirrhotics to the already well-arranged review [ [1] Ferro D. Angelico F. Caldwell S.H. et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Digestive and Liver Disease. 2012; 44: 275-279 Abstract Full Text Full Text PDF Scopus (35) Google Scholar ]. Table 1Cirrhotic patients who underwent upper endoscopy with biopsies. Patients (N) Gastric biopsies Platelets (N/mm3) PT* % Reference 30 4 >45,000 45 Zullo A et al. Ital J Gastroenterol Hepatol 1998;30:405–9 83 6 >50,000 50 Zullo A et al. Ital J Gastroenterol Hepatol 1999;31:831–5 226 6 >45,000 45 Zullo A et al. Hepatogastroenterology 1999;46:395–400 47 6 >45,000 45 Zullo et al. Am J Gastroenterol 1999;94:2214–8 30 6 >50,000 50 Zullo A et al. Dig Liver Dis 2000;32:836–8 36 6 >45,000 45 Zullo A et al. Dig Dis Sci 2001;46:550–4 46 6 >45,000 45 Chakrabarti P et al. J Clin Gastroenterol 2002;34:578–81 53 6 >50,000 50 Sanchez-Mete L et al. Dig Liver Dis 2003;35:566–70 36 4 >50,000 50 Zullo A et al. J Gastroenterol Hepatol 2004;19:1174–8 Prothrombin activity expressed as a percentage. Open table in a new tab Prothrombin activity expressed as a percentage.