Hemostatic studies in obstructive jaundice

Abstract

Hemostatic studies were performed in 64 patients with obstructive jaundice. Elevated fibrinogen level, shortened “r” and “r+k” and increased “ma” in thrombelastogram, prolonged serial tbrombin time, elevated fibrin degradation products, positive ethanol gelation test, decreased plasminogen activator activity, increased antiplasmin activity and increased α1-antitrypsin level were observed. All of these changes were statistically significant when compared with normal controls. In addition, levels of antithrombin-III and plasminogen decreased, but no significance was observed statistically. These hemostatic data revealed the presence of hypercoagulable state with decreased fibrinolytic activity and several evidences of intravascular coagulation.In order to elucidate the cause of these characteristic patterns in hemostatic studies, the correlation between these hemostatic parameters and liver function tests was studied. Changes in prothrombin time, plasminogen and antithrombin-III were well correlated with albumin, γ-globulin and TTT which mainly reflect liver cellular damage. Accordingly, low levels of plasminogen and antithrombin-III in some cases of this series may be attributable not only to enhanced consumption, but also to decreased synthesis in liver. In addition, serum fibrinogen level which is the most important factor in this hypercoagulable state showed positive correlation with alkaline phosphatase and cholesterol which reflect the degree of biliary obstruction.Six out of 64 cases were diagnosed as disseminated intravascular coagulation (DIC). Five of 6 cases were complicated with biliary infection. In this series, bacteriological examination of bile was performed in 43 cases and gram negative bacilli were found in 32 cases. In addition, 22 cases eventually suffered from cholangitis.Recently we experienced a very interesting patient with massive bleeding tendency complicated with biliary infection. High antiactivator activity in a low molecular weight fraction was detected in the gel filtration pattern of Lysine Sepharose treated serum through G-200 Sephadex. From these observations it is suggested that this low molecular fraction may have an important role in the decreased fibrinolytic activity in obstructive jaundice.The present study revealed the presence of hyper-coagulable state in obstructive jaundice which may be easely leading to DIC.