A prospective study of conventional and expanded coagulation indices in predicting ulcer bleeding after variceal band ligation.
OBJECTIVE
There is controversy over whether coagulation status predicts bleeding caused by ulceration after esophageal varices band ligation (EVL).


METHODS
EVL was performed for primary (n = 45) or secondary (n = 105) prophylaxis in 150 patients with cirrhosis (Child A, n = 74, 49%; Child B, n = 42, 28%; Child C, n = 34, 23%). International normalized ratio (INR) and platelet counts were assessed in all. In 92 patients, levels of factor V, fibrinogen, D-dimer, protein C and protein S, von Willebrand factor, and thromboelastography (TEG) were assessed. Platelet count <50 x 10(3)/mm(3) and INR >1.5 were considered high-risk cutoff for bleeding. Conversely, platelet count >or=50 x 10(3)/mm(3) with INR <or=1.5 were safe cutoffs.


RESULTS
Overall, 11 patients (7.3%) had post-EVL ulcer bleeding. Bleeding occurred in 5 patients with Child A/B (4.3%) and 6 patients with Child C (17%) (P = .0174 for Child A/B versus Child C). Eight patients with bleeding were among the 110 below the cutoff for INR and platelet count, whereas only 3 of the patients with bleeding were among the 40 patients with purported high-risk values (P = 1.0). Among the 92 patients with expanded coagulation tests, bleeding occurred in 5. There was no difference in any of the coagulation parameters, including overall TEG patterns, between patients who did and did not bleed.


CONCLUSIONS
Post-EVL ulcer bleeding was associated with Child C status but not with conventional or expanded coagulation indices in cirrhotic patients without renal failure or infection undergoing elective EVL. These results call into question the common use of prophylactic procoagulants in the elective setting.
Vieira da Rocha
Evandra Cristina
EC
University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
D'Amico
Elbio Antonio
EA
Caldwell
Stephen Hugh
SH
Flores da Rocha
Tania Rubia
TR
Soares E Silva
Cristina Simões Solon
CS
Dos Santos Bomfim
Valdinelia
V
Felga
Guilherme
G
Barbosa
Walnei Fernandes
WF
Kassab
Fabio
F
Polli
Demerson Andre
DA
Carrilho
Flair Jose
FJ
Farias
Alberto Queiroz
AQ
D000925:Anticoagulants / Q000008:administration & dosage*; D003131:Combined Modality Therapy; D004932:Esophageal and Gastric Varices / Q000097:blood* / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D019934:International Normalized Ratio; D008026:Ligation; D008103:Liver Cirrhosis / Q000097:blood* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010976:Platelet Count; D019106:Postoperative Hemorrhage / Q000453:epidemiology* / Q000517:prevention & control; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors
D000925:Anticoagulants