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Communications to the Editor |

Pulmonary Embolism in a Patient With Coagulopathy From End-Stage Liver Disease FREE TO VIEW

Joseph D. Espiritu, MD
Author and Funding Information

St. Louis University Health Sciences Center St. Louis, MO

Correspondence to: Joseph D. Espiritu, MD, Division of Pulmonary and Critical Care Medicine, St. Louis University Health Sciences Center, 3635 Vista Avenue at Grand Boulevard, P.O.Box 15250, St. Louis, MO 15250; e-mail: joydoc@ezl.com



Chest. 2000;117(3):924-925. doi:10.1378/chest.117.3.924-a
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To the Editor:

The American College of Chest Physicians has published guidelines on the prevention of venous thromboembolism.1 Although these guidelines were fairly comprehensive, they failed to address the prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) occurring among patients with coagulopathy from end-stage liver disease.

Virtually all patients with end-stage liver disease have some component of coagulopathy due to hepatic synthetic dysfunction with failure to manufacture coagulation factors II, VII, IX, and X.2 Meanwhile, they are also at risk for DVT and PE because of an inability to synthesize anticoagulating factors such as protein C, protein S, and antithrombin III.3 The following case summary illustrates these coagulopathic abnormalities.

A 57-year-old man was admitted to our Medical ICU (MICU) for refractory ascites. He had been suffering from alcoholic cirrhosis for 2 years, with a baseline serum albumin of 2.8 g/dL, total bilirubin of 1.4 mg/dL, and an international normalized ratio of 1:3. During his MICU stay, he required large-volume paracentesis every 48 to 72 h for massive ascites. Other acute problems included upper GI bleeding from esophageal varices that were treated with banding, and nonspecific colitis, which resolved with nasogastric suctioning and rectal tube drainage. With improvement of these problems, he was subsequently listed for liver transplantation. He had been on intermittent pneumatic compression stockings throughout his MICU stay. On the 23rd hospital day, he developed respiratory distress and severe hypoxemia requiring intubation and mechanical ventilation. A lung perfusion scan showed multiple perfusion defects consistent with PE, so an inferior vena cava filter was placed. However, the patient died 2 days later, after his wife requested the withdrawal of life support.

This case demonstrates that PE may occur among patients who are supposed to be auto-anticoagulated due to their liver disease. It also illustrates that intermittent pneumatic compression may not be adequate for DVT prophylaxis among patients with advanced liver disease. To date, there are no available alternatives to nonpharmacologic prophylaxis for venous thromboembolism in these patients. A search for a safe and effective prophylactic modality for DVT and PE is much needed to improve the outcome of end-stage liver patients awaiting transplantation.

References

Clagett, GP, Anderson, FA, Geerts, WH, et al (1998) Prevention of venous thromboembolic disease: Fifth ACCP Consensus Conference on Antithrombotic Therapy.Chest114(suppl),531S-549S
 
Mammen, EF Coagulation abnormalities in liver disease.Hematol Oncol Clin North Am1992;6,1247-1257
 
Castelino, DJ, Salem, HH Natural anticoagulants and the liver.J Gastroenterol Hepatol1997;12,77-83
 

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References

Clagett, GP, Anderson, FA, Geerts, WH, et al (1998) Prevention of venous thromboembolic disease: Fifth ACCP Consensus Conference on Antithrombotic Therapy.Chest114(suppl),531S-549S
 
Mammen, EF Coagulation abnormalities in liver disease.Hematol Oncol Clin North Am1992;6,1247-1257
 
Castelino, DJ, Salem, HH Natural anticoagulants and the liver.J Gastroenterol Hepatol1997;12,77-83
 
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