Vitamin K Administration in Ascending Cholangitis
Parenteral vitamin K should be given prophylactically prior to any invasive procedure (such as ERCP for biliary drainage) in patients with ascending cholangitis who have overt cholestasis, and should also be administered in the context of active bleeding. 1
Clinical Context and Rationale
Ascending cholangitis causes biliary obstruction leading to cholestasis, which impairs fat-soluble vitamin absorption including vitamin K. 2, 3 This creates a true vitamin K deficiency state (distinct from hepatic synthetic dysfunction in cirrhosis), making vitamin K supplementation effective in this population. 4
The key distinction: In cholestatic conditions like ascending cholangitis, vitamin K deficiency occurs due to malabsorption from bile duct obstruction, not from loss of hepatic synthetic function. 1 This is why vitamin K is effective in cholestasis but not in decompensated cirrhosis. 4, 5
Specific Indications for Vitamin K
Before Invasive Procedures
- Parenteral (IV) vitamin K should be given prophylactically before ERCP or any invasive biliary procedure in patients with overt cholestasis. 1
- The rationale is that biliary drainage procedures carry bleeding risk, and cholestasis-induced vitamin K deficiency increases coagulopathy. 1
Active Bleeding
- Parenteral vitamin K should be administered immediately in the context of any bleeding in cholestatic patients. 1
Chronic Cholestasis Management
- Enteral vitamin K supplementation should be given to adults with overt cholestasis, particularly when clinical features of steatorrhea are present. 1
- Regular PT monitoring is recommended in pregnant women with cholestatic conditions. 1
Dosing and Route
The recommended dose is 10 mg administered parenterally (IV preferred). 4
- IV administration is preferred over subcutaneous because subcutaneous vitamin K is relatively ineffective and does not reliably modify coagulation parameters in cholestatic liver disease. 4, 6
- IV vitamin K begins to reduce INR within 8 hours, whereas subcutaneous administration is ineffective. 6
- Administer IV vitamin K by slow injection (not to exceed 10 mg per dose) to minimize risk of anaphylactoid reactions, which occur in approximately 3 per 100,000 doses. 4
What NOT to Do
Do not exceed 10 mg doses of vitamin K, as higher doses can create a prothrombotic state and prevent re-anticoagulation for days. 4
Do not use vitamin K routinely in non-cholestatic liver disease or cirrhosis, as it is ineffective when the problem is hepatic synthetic dysfunction rather than true vitamin K deficiency. 4, 7, 5 In cirrhosis, vitamin K has minimal to no role and does not effectively correct INR or reduce bleeding risk. 4
Clinical Pearls
- Cholestyramine (often used for pruritus in cholestasis) can exacerbate vitamin K deficiency, with case reports of hypoprothrombinemia and hemorrhage occurring 2 weeks to 8 months after initiation. 1
- Response to vitamin K confirms true vitamin K deficiency: improvement in INR by ≥0.5 within 24-72 hours after 10 mg IV/SC vitamin K distinguishes vitamin K deficiency from pure hepatic synthetic dysfunction. 4
- In cholestatic liver disease, IV vitamin K may temporarily correct INR, but has minimal effect in other forms of liver failure. 4, 5