From the Guidelines
Liver bleeding, or hepatic hemorrhage, can occur due to various causes including trauma, liver disease, tumors, and certain medical procedures, with the most recent evidence suggesting that portal hypertension and mechanical vessel injury are more significant contributors to bleeding than haemostatic failure 1.
Causes of Liver Bleeding
- Trauma, such as blunt force injuries from car accidents or falls, can rupture blood vessels in the liver.
- Liver diseases like cirrhosis, hepatitis, or fatty liver disease can weaken the organ's structure, making it more prone to bleeding.
- Tumors, both benign and malignant, can erode blood vessels and cause hemorrhage.
- Medical procedures like liver biopsies or surgeries carry a risk of bleeding complications.
- Certain medications, particularly blood thinners like warfarin, heparin, or newer anticoagulants, can increase bleeding risk.
- Coagulation disorders that impair blood clotting, such as hemophilia or disseminated intravascular coagulation (DIC), may also lead to liver hemorrhage.
Haemostatic Changes in Liver Disease
The haemostatic system in patients with liver disease is often referred to as 'rebalanced', with a net effect of normal haemostasis or even a procoagulant state, as evidenced by more 'global' assays of coagulation, such as thrombin generation and viscoelastic haemostatic assays 1.
Management of Bleeding in Liver Disease
The use of blood products, such as fresh frozen plasma (FFP) and platelets, should be sparing, as they can increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunisation, and/or transfusion reactions 1.
Recent Guidelines and Recommendations
Recent guidelines from the American Gastroenterology Association recommend that blood products should be used sparingly, and that the administration of vitamin K to correct prolongations in INR is not supported by evidence 1.
Future Perspectives
Large observational studies are needed to define the precise incidence of spontaneous bleeding events and their impact on clinical course and survival of patients with cirrhosis, and to evaluate the effectiveness of different management strategies, including the use of thrombopoietin receptor agonists (TPO-RAs) and viscoelastic assays to assess haemostatic status 1.
From the FDA Drug Label
Vitamin K1 Injection (Phytonadione Injectable Emulsion, USP) aqueous dispersion of vitamin K1 for parenteral injection, possesses the same type and degree of activity as does naturally-occurring vitamin K, which is necessary for the production via the liver of active prothrombin (factor II), proconvertin (factor VII), plasma thromboplastin component (factor IX), and Stuart factor (factor X). The liver can bleed due to a lack of vitamin K, which is necessary for the production of clotting factors.
- Vitamin K deficiency can lead to impaired clotting factor production, resulting in bleeding. 2
From the Research
Causes of Liver Bleeding
The liver can bleed due to various reasons, including:
- Coagulopathy, which is a condition characterized by impaired blood clotting, often seen in patients with liver disease 3, 4, 5
- Cirrhosis, which can lead to a dynamic disequilibrium between procoagulant and anticoagulant states, increasing the risk of both thrombosis and bleeding 4, 6
- Decreased synthetic function of the liver, leading to a lack of natural anticoagulants 4
- Decreased platelet production and increased platelet destruction due to hypersplenism 4
- Alterations in purinergic signaling pathways 4
- Portal hypertension, which can cause pressure-driven bleeding 6
Underlying Mechanisms
The underlying mechanisms of liver bleeding are complex and involve:
- Impairments in the clotting and fibrinolytic systems 3
- Reduced number and function of platelets 3
- Decreased synthesis of Vitamin K-dependent and independent clotting factors and anticoagulant factors 4
- Inherited forms of thrombophilia, which may not outweigh the thrombophilia inherent to liver disease 6
Associated Conditions
Liver bleeding can be associated with various conditions, including:
- Thrombocytopenia, which is a low platelet count 5
- Impaired humoral coagulation, as measured by prolongation of the prothrombin time and international normalized ratio 5
- Venous thrombosis, which is a common complication of cirrhosis 4, 6
- Infections and renal dysfunction, which can superimpose and complicate the management of liver bleeding 6