Clinical Significance Of Conventional Coagulation Tests And The Platelet Count In Prediction Of Bleeding In Liver Cirrhosis

Background and Aims Esophageal gastric varices bleeding was one of the common complications in patients with decompensated liver cirrhosis.And patients with cirrhosis often require invasive examinations and treatments in the clinical course.Therefore,it was very important to evaluate the bleeding risk carefully in patients with cirrhosis.Clinical had often combine detection with conventional coagulation and platelet counts to assess risk of bleeding in patients with cirrhosis.However,there were evidences that prothrombin time(PT)and international standardization ratio(INR)can not evaluate the bleeding tendency of patients with cirrhosis.This study researched the difference of platelet count(PLT),PT/INR and activated partial prothrombin time(APTT)in patients with cirrhosis to clarify the relationship between conventional coagulation tests and platelet counts with upper gastrointestinal bleeding,and to cheak the association of coagulopathy with the risk of bleeding after liver cirrhosis patients with invasive procedures.Methods 1.The frist retrospective study enrolled a total of 1734 cirrhotic patients in our hospital between January 2012 and June 2014 and were classified into acute upper gastrointestinal bleeding(AUGIB)(n=497)and ‘no AUGIB'(n=1237)groups according to their disease history.They were further divided into acute oesophageal variceal bleeding(AEVB)(n=297)and ‘no AEVB'(n=1259)groups according to the endoscopic findings.Additionally,178 patients with AUGIB were not assigned to either the ‘AEVB' or ‘no AEVB' groups due to the absence of any endoscopic findings.2.The second retrospective study enrolled 874 cirrhotic patients with invasive procedures in our hospital between January 2011 and June 2014.According to the laboratory results to determine whether there was a coagulopathy,then divided the patients into ‘coagulopathy' and ‘no coagulopathy'groups,‘severe thrombocytopenia' and ‘no severe thrombocytopenia' groups,and ‘INR?1.5' and ‘INR<1.5' groups.Coagulopathy was defined as INR?1.5 and/or platelet count ?50×10~9/L.Severe thrombocytopenia was defined as platelet counts ?50×10~9/L.Invasive procedures and incidences of procedure-related bleeding were recorded for each patient.Results 1.The frist retrospective study found that compared with the ‘no AUGIB' group,the ‘AUGIB' group had similar PLT(99.99±89.90 vs 101.47±83.03;P=0.734)and APTT(42.96±15.20 vs 43.77±11.01;P=0.219),but significantly higher PT(17.30±5.62 vs 16.03±4.68;P<0.001)and INR(1.45±0.69 vs 1.31±0.59;P<0.001).A lower PT was independently associated with the absence of AUGIB(OR=0.968;95%CI:0.942–0.994;P=0.015).Compared with the ‘no AEVB' group,the ‘AEVB' group had significantly lower PLT(86.87±62.14 vs 101.74±83.62;P=0.004)and APTT(40.98±7.9 vs 43.72±10.97;P<0.001),but similar PT(16.53±3.71 vs 16.04±4.68;P=0.088)and INR(1.35±0.41 vs 1.31±0.59;P=0.225).A higher PLT was independently associated with the absence of AEVB(OR=1.004;95%CI:1.002–1.006;P=0.001).2.The second retrospective study brought out that 296 patients(33.9%)were qualified in coagulopathy group.Endoscopic band ligation was the most common type of invasive procedures carried in the two groups.It was carried out in ‘coagulopathy' and ‘no coagulopathy'groups 18.6% and 18.5% respectivly.Followed by abdominocentesis it was carried out 17.2% and 13.8% respectivly.A total of 21 cases of bleeding after invasive procedures(2.40%).Compared with ‘no coagulopathy'group,‘coagulopathy' group had significantly higher bleeding cases(4.1% vs 1.6%;P=0.023)and in-hospital mortality(3.7% vs 1.4%;P=0.025).Compared with ‘no severe thrombocytopenia' group,the ‘severe thrombocytopenia'group had significantly higher bleeding cases(4.9% vs 1.6%;P=0.008).Compared with ‘INR?1.5' group and ‘INR<1.5' group had similar bleeding cases(4.5% vs 2.0%;P=0.065),but ‘INR?1.5' group had significantly higher in-hospital mortality(6.4% vs 1.3%;P<0.001).In patients with cirrhosis and coagulopathy following invasive procedures,the bleeding group had significantly higher mortality than the non-bleeding group(16.7% vs 3.2%;P=0.015).Conclusion 1.The frist retrospective study shows that PLT was associated with the occurrence of portal hypertension-related bleeding in liver cirrhosis.2.The second retrospective study had shown that patients with coagulopathy especially having severe thrombocytopenia had significantly higher bleeding cases than patients without coagulopathy following invasive procedures.INR did not predict clinically significant bleeding following invasive procedures in cirrhosis.But INR might be more closely related to the prognosis of patients with invasive procedures in cirrhosis.3.The conclusion of the two retrospective studies were consistent basically,But because of the two studies with the patients' conditions,sample size and research conditions were different,the conclusion was a little different.Judging from the present study,it seemed that the predictive value of platelet count being higher in cirrhosis related bleeding,the INR could not serve as a reliable predictor of bleeding in cirrhosis.