What should be administered to correct the coagulopathy in a patient with gastric malignancy and outlet obstruction who has prolonged PT/INR and aPTT?

Management of Coagulopathy in Gastric Malignancy with Outlet Obstruction

In a patient with gastric malignancy and outlet obstruction presenting with elevated PT/INR and aPTT, immediately administer fresh frozen plasma (FFP) 10-15 mL/kg (approximately 2-4 units for a 70 kg adult) to correct the coagulopathy, along with vitamin K 10 mg intravenously, because the combined elevation of both PT/INR and aPTT indicates multiple coagulation factor deficiencies that require urgent correction before any endoscopic or surgical intervention. 1, 2

Understanding the Coagulopathy

The combination of prolonged PT/INR and aPTT in this clinical context most likely reflects:

• Vitamin K deficiency from prolonged gastric outlet obstruction causing malnutrition and impaired absorption of fat-soluble vitamins 3, 4
• Hepatic synthetic dysfunction if there is liver involvement by malignancy 1
• Consumptive coagulopathy in the setting of advanced malignancy 5

The gastric outlet obstruction prevents adequate oral intake and absorption, leading to depletion of vitamin K-dependent clotting factors (II, VII, IX, X), which manifests as prolonged PT/INR. 3, 6

Immediate Correction Strategy

Fresh Frozen Plasma (FFP)

Administer FFP 10-15 mL/kg body weight immediately to achieve a minimum of 30% plasma factor concentration, which typically requires 2-4 units (500-1000 mL) for an average adult. 1, 2

• FFP is indicated when PT is >1.5 times normal or INR >2.0, AND aPTT is >2 times normal, particularly if any intervention (endoscopy, surgery, or stenting) is planned 1, 2
• FFP provides immediate replacement of all coagulation factors, including vitamin K-dependent factors 1
• For urgent reversal in preparation for a procedure, 5-8 mL/kg FFP usually suffices 1
• FFP must be ABO-compatible with the recipient 2

Concurrent Vitamin K Administration

Give vitamin K (phytonadione) 10 mg intravenously by slow infusion concurrently with FFP to provide sustained correction of the coagulopathy. 3, 6, 4

• The intravenous route provides correction within 2-4 hours, though FFP acts immediately 3, 6
• Vitamin K 10 mg is the appropriate dose for severe coagulopathy (INR >2.0) in adults 3, 4
• Administer by slow IV infusion (over 20-30 minutes) to minimize risk of anaphylactoid reactions 6, 4
• Vitamin K provides lasting correction by restoring hepatic synthesis of vitamin K-dependent factors, while FFP provides only temporary factor replacement 6, 4

Monitoring and Re-assessment

• Recheck PT/INR and aPTT 2-4 hours after FFP and vitamin K administration to assess response 5, 3
• A prompt response (shortening of PT within 2-4 hours) confirms the diagnosis of nutritional/malabsorption-related coagulopathy 3
• Failure to respond suggests consumptive coagulopathy (DIC) or severe hepatic dysfunction requiring additional evaluation 5, 3

If Fibrinogen is Low (<1.0 g/L)

• Add cryoprecipitate for more efficient fibrinogen replacement if levels remain <1.0 g/L despite FFP 2, 5
• Cryoprecipitate is preferred over FFP for isolated hypofibrinogenemia 2

Platelet Management

If platelet count is <50 × 10⁹/L, transfuse platelets to maintain count >50 × 10⁹/L before any invasive procedure. 1, 5

• For procedures with higher bleeding risk or if planning surgery, target platelet count >100 × 10⁹/L 1, 5
• Combined coagulopathy and thrombocytopenia create synergistic bleeding risk requiring simultaneous correction 5

Timing of Endoscopy or Intervention

Do not delay necessary endoscopy or intervention while correcting coagulopathy unless INR is markedly supratherapeutic (>2.5-3.0), as early intervention improves outcomes in upper GI pathology. 1

• Endoscopic treatment can be safely performed with INR <2.5 after correction with FFP 1
• The goal is to correct INR to <1.8-2.0 before high-risk procedures 1
• Intensive correction of coagulopathy reduces mortality in patients with upper GI bleeding and may prevent bleeding complications during stenting or surgical palliation 1

Common Pitfalls to Avoid

• Do not use FFP for volume expansion or albumin replacement—it is indicated only for coagulation factor deficiency with documented coagulopathy 1, 2
• Do not give vitamin K alone without FFP in urgent situations—vitamin K takes 2-4 hours to work, too slow for immediate correction before procedures 3, 6
• Do not use subcutaneous vitamin K—the oral or intravenous routes are preferred; subcutaneous administration is unreliable and may cause cutaneous reactions 6, 4
• Do not assume warfarin use—in gastric outlet obstruction, vitamin K deficiency from malnutrition is the more likely cause 3, 4

Special Considerations in Malignancy

In cancer patients with coagulopathy:

• Drug interactions, malnutrition, and liver dysfunction commonly cause wide fluctuations in coagulation parameters 1
• Cancer patients have higher rates of both thrombosis and bleeding complications 1
• The presence of coagulopathy (INR ≥1.5) is a significant predictor of mortality in patients with GI pathology, emphasizing the importance of correction 1