The Hemostatic Defect of Liver Disease

Abstract

Excessive hemorrhage is not uncommon in liver disease and laboratory tests of hemostasis are frequently abnormal. Significant hypofibrinogenemia is rare. Hyperfibrinogenemia may occur in hepatocellular disease and is usual in tumors involving the liver and in obstructive jaundice. In hepatocellular disease, levels of factors II, V, VII, IX, X, XI, and XIII are frequently subnormal while factor VIII activity remains unchanged. Factors II, VII, and X may also be diminished in tumors of the liver and obstructive jaundice whereas factors V and VIII tend to be increased. Factor XIII activity may also be subnormal in tumors of the liver but is usually normal in obstructive jaundice. Excessive fibrinolysis has frequently been observed in cirrhosis of the liver. Quantitative and qualitative platelet defects also occur, as does consumption coagulopathy due to intravascular coagulation. Circulating anticoagulants have occasionally been described and increased capillary fragility has been demonstrated. Thromboelastographic changes are common in diseases of the liver and biliary system, reflecting changes in levels of coagulation factors and probably platelet function. Excessive hemorrhage in liver disease is probably due to a combination of the above factors rather than to a single abnormality. The clinical implications are discussed.