Management of coagulopathy among patients with cirrhosis undergoing upper endoscopy and paracentesis: Persistent gaps and areas of consensus in a multispecialty Delphi

Elliot B Tapper; Matthew A Warner; Rajesh P Shah; Juliet Emamaullee; Nancy M Dunbar; Michelle Sholzberg; Jacqueline N Poston; Robin J Soto; Ammar Sarwar; Anjana Pillai; Karina Reyner; Shivang Mehta; Marwan Ghabril; Timothy R Morgan; Stephen Caldwell

doi:10.1097/HEP.0000000000000856

Management of coagulopathy among patients with cirrhosis undergoing upper endoscopy and paracentesis: Persistent gaps and areas of consensus in a multispecialty Delphi

Hepatology. 2024 Apr 1. doi: 10.1097/HEP.0000000000000856. Online ahead of print.

Authors

Elliot B Tapper¹, Matthew A Warner², Rajesh P Shah³, Juliet Emamaullee⁴, Nancy M Dunbar⁵, Michelle Sholzberg⁶, Jacqueline N Poston^{7

8}, Robin J Soto⁹, Ammar Sarwar¹⁰, Anjana Pillai¹¹, Karina Reyner¹², Shivang Mehta¹³, Marwan Ghabril¹⁴, Timothy R Morgan¹⁵, Stephen Caldwell¹⁶

Affiliations

¹ Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.
² Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
³ Section of Radiology-Veterans Affairs Palo Alto Health Care System, Department of Radiology, Stanford University, Stanford, California, USA.
⁴ Department of Surgery, Keck Medicine of USC/Children's Hospital-Los Angeles, Los Angeles, California, USA.
⁵ Department of Pathology and Laboratory Medicine and Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
⁶ Departments of Medicine and Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada.
⁷ Department of Medicine, Division of Hematology/Oncology, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA.
⁸ Department of Pathology, Division of Clinical Pathology, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA.
⁹ Division of Gastroenterology and Hepatology, UC San Diego Health, San Diego, California, USA.
¹⁰ Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
¹¹ Division of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois, USA.
¹² Department of Emergency Medicine, Baylor Scott and White, Dallas, Texas, USA.
¹³ Division of Transplant Hepatology, Baylor Scott and White, Fort Worth, Texas, USA.
¹⁴ Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
¹⁵ VA Long Beach Healthcare System-Section of Gastroenterology, Long Beach, California, USA.
¹⁶ Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA.

PMID: 38557474
DOI: 10.1097/HEP.0000000000000856

Abstract

Patients with cirrhosis have abnormal coagulation indices such as a high international normalized ratio and low platelet count, but these do not correlate well with periprocedural bleeding risk. We sought to develop a consensus among the multiple stakeholders in cirrhosis care to inform process measures that can help improve the quality of the periprocedural management of coagulopathy in cirrhosis. We identified candidate process measures for periprocedural coagulopathy management in multiple contexts relating to the performance of paracentesis and upper endoscopy. An 11-member panel with content expertise was convened. It included nominees from professional societies for interventional radiology, transfusion medicine, and anesthesia as well as representatives from hematology, emergency medicine, transplant surgery, and community practice. Each measure was evaluated for agreement using a modified Delphi approach (3 rounds of rating) to define the final set of measures. Out of 286 possible measures, 33 measures made the final set. International normalized ratio testing was not required for diagnostic or therapeutic paracentesis as well as diagnostic endoscopy. Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy. No consensus was achieved for these items in therapeutic intent or emergent endoscopy. The risks of prophylactic platelet transfusions exceed their benefits for outpatient diagnostic paracentesis and diagnostic endosopies. For the other procedures examined, the risks outweigh benefits when platelet count is >20,000/mm 3 . It is uncertain whether risks outweigh benefits below 20,000/mm 3 in other contexts. No consensus was achieved on whether it was permissible to continue or stop systemic anticoagulation. Continuous aspirin was permissible for each procedure. Clopidogrel was permissible for diagnostic and therapeutic paracentesis and diagnostic endoscopy. We found many areas of consensus that may serve as a foundation for a common set of practice metrics for the periprocedural management of coagulopathy in cirrhosis.