title: Iatrogenic vitamin K deficiency and life threatening coagulopathy.
abstract: A man was admitted with abdominal pain. Treatment for acute diverticulitis was instituted with intravenous antibiotics and oral limitation. Imaging demonstrated a complex inflammatory mass. Prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen were within normal limits. However, repeat preoperative clotting studies demonstrated a severe unexpected coagulopathy to have developed since admission that could have caused fatal intraoperative exsanguination. Direct assays showed severe, isolated deficiency of vitamin K dependent clotting factors, and mixing studies normalised both the PT and APTT, ruling out a coagulation inhibitor. The coagulopathy responded to intravenous vitamin K administration. Dietary insufficiency underlies vitamin K deficiency in the presence of normal biliary and enteral function. A significant coagulopathy can result with additional eradication of intestinal microflora. Hypoprothombinaemia is recognised as a consequence of protracted treatment with broad spectrum antibiotics, and vigilance is required for those at risk. The development of such a rapid and unexpected coagulopathy posed a complex preoperative management issue delaying operative intervention; although avoided by fortuitous preoperative screening, it could have caused significant intraoperative bleeding. The remarkably specific lack of vitamin K dependent clotting factors strongly suggested a vitamin K deficiency and administration of coumarins was ruled out.
authors.affiliation: Cheltenham General Hospital, General Surgery, Sandford Road, Cheltenham, GL537AN, UK. samuelford@hotmail.co.uk
authors.forename: Samuel John
authors.initials: SJ
authors.lastname: Ford
authors.forename: Alistair
authors.initials: A
authors.lastname: Webb
authors.forename: Richard
authors.initials: R
authors.lastname: Payne
authors.forename: Norbert
authors.initials: N
authors.lastname: Blesing
mesh_terms: D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D004238:Diverticulitis / Q000188:drug therapy; D006801:Humans; D007020:Hypoprothrombinemias / Q000139:chemically induced* / Q000188:drug therapy; D008297:Male; D014812:Vitamin K / Q000627:therapeutic use; D014813:Vitamin K Deficiency / Q000139:chemically induced* / Q000150:complications / Q000188:drug therapy
chemical_list: D000900:Anti-Bacterial Agents; D000933:Antifibrinolytic Agents; D014812:Vitamin K