Causes of Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC) is always secondary to an underlying disorder, most commonly sepsis, malignancy, trauma, or complications of surgery and pregnancy. 1
Primary Underlying Conditions
- Sepsis and Infection: Sepsis is one of the most common causes of DIC, with significant endothelial dysfunction contributing to sepsis-induced coagulopathy 2
- Malignancy: Various cancers can trigger DIC, with pancreatic cancer and adenocarcinomas posing particularly high risks 2, 1
- Trauma: Physical trauma, especially severe injuries, can initiate the DIC process through tissue damage and release of procoagulant substances 1, 3
- Obstetrical Complications: Pregnancy-related complications such as eclampsia, placental abruption, and amniotic fluid embolism can trigger DIC 1, 4
- Acute Liver Failure: Severe liver dysfunction can lead to DIC through multiple mechanisms including decreased clearance of activated coagulation factors 2
Pathophysiological Mechanisms
- Endothelial Injury: According to the International Society on Thrombosis and Haemostasis (ISTH), endothelial injury is an essential component of DIC in addition to systemic coagulation activation 2
- Tissue Factor Release: Abnormal tissue factor expression is a major mechanism initiating DIC in many disorders 5
- Systemic Inflammation: Inflammatory mediators trigger the coagulation cascade, particularly in sepsis where endotoxin absorption leads to sustained inflammation 2, 4
- Complement Activation: The terminal complement complex C5b-9 can cause endotheliopathy via channel formation in the endothelial cell membrane 6
- Impaired Anticoagulant Mechanisms: Decreased levels of natural anticoagulants (protein C, protein S, antithrombin) contribute to uncontrolled coagulation 2
Disease-Specific Mechanisms
Cancer-Associated DIC: Can present in three forms 2, 1:
- Procoagulant DIC: Common in pancreatic cancer and adenocarcinomas, characterized by thrombotic complications
- Hyperfibrinolytic DIC: Common in acute promyelocytic leukemia and metastatic prostate cancer, characterized by bleeding complications
- Subclinical DIC: No obvious clinical symptoms but laboratory abnormalities present
Sepsis-Induced DIC: Involves significant endothelial dysfunction with high mortality (24.8% reported in a Japanese nationwide study) 2
Liver Disease-Associated DIC: Multiple mechanisms including activation of coagulation factors in the low-flow portal system, endotoxin absorption from intestines, and hepatocyte necrosis with tissue factor release 2
Clinical Implications
The pathophysiology of DIC varies significantly depending on the underlying cause, with different patterns of endothelial dysfunction observed in sepsis (significant), trauma (moderate), and hematologic malignancies (variable) 2
Understanding the specific mechanism of DIC is crucial for appropriate management, as treatment approaches differ based on whether the presentation is predominantly procoagulant, hyperfibrinolytic, or subclinical 2, 1
Early detection of DIC is beneficial for predicting outcomes and managing critically ill patients, with the ISTH recommending screening for sepsis-induced coagulopathy in patients with sepsis 2
The mortality risk is substantial, with recent data showing nearly 25% mortality in septic patients with DIC 2