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Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients.These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation. Resumen: El manejo de la coagulación en el paciente con cirrosis ha sufrido una transformación significativa a partir de principios de este siglo, con el concepto de un rebalanceo entre factores procoagulantes y anticoagulantes. Esto ha cambiado el paradigma de que los pacientes con cirrosis tienen una mayor tendencia a la hemorragia, ya que existe un rebalanceo entre factores procoagulantes y anticoagulantes. Además, ha traído a la luz la presencia de complicaciones relacionadas a eventos trombóticos en este grupo de pacientes.En estas guías se detallan aspectos relacionados con los mecanismos fisiopatológicos que intervienen en el mantenimiento de la hemostasia en el paciente con cirrosis, la relevancia de la hipertensión portal, factores mecánicos para el desarrollo de sangrado, modificaciones en la síntesis hepática de factores de coagulación, y los cambios en el sistema reticuloendotelial en la descompensación hepática aguda e insuficiencia hepática aguda sobre crónica (IHAC). Se abordan nuevos aspectos relacionados a las complicaciones hemorrágicas en pacientes con cirrosis, considerando el riesgo de hemorragia durante procedimientos diagnósticos o terapéuticos, así como la utilidad de diferentes herramientas diagnósticas de la coagulación y recomendaciones en el tratamiento farmacológico y transfusión de hemoderivados en el contexto de hemorragia. En estas guías se actualiza el conocimiento respecto al diagnóstico y abordaje de complicaciones relacionadas a hipercoagulabilidad en el paciente con cirrosis, así como la eficacia y seguridad del tratamiento con diferentes esquemas de anticoagulación. Finalmente, se mencionarán recomendaciones en el manejo de la coagulación en el contexto de IHAC, descompensación hepática aguda y aspectos específicos relacionados al paciente en protocolo de trasplante hepático.

Resumen: El manejo de la coagulación en el paciente con cirrosis ha sufrido una transformación significativa a partir de principios de este siglo con el concepto de un rebalanceo entre los factores procoagulantes y anticoagulantes. Esto ha cambiado el paradigma de que las personas con esta enfermedad tienen una mayor tendencia a la hemorragia. Además, ha traído a la luz la presencia de complicaciones relacionadas a eventos trombóticos en este grupo de sujetos.En estas guías se detallan aspectos asociados con los mecanismos fisiopatológicos que intervienen en el mantenimiento de la hemostasia en el paciente con cirrosis, la relevancia de la hipertensión portal, los factores mecánicos para el desarrollo de sangrado, las modificaciones en la síntesis hepática de los factores de coagulación, y los cambios en el sistema reticuloendotelial en la descompensación hepática aguda e insuficiencia hepática aguda sobre crónica (IHAC). Se abordan nuevos aspectos vinculados a las complicaciones hemorrágicas en sujetos con esta entidad, considerando el riesgo de hemorragia durante los procedimientos diagnósticos o terapéuticos, así como la utilidad de diferentes herramientas diagnósticas de la coagulación y recomendaciones en el tratamiento farmacológico y transfusión de hemoderivados en el contexto de hemorragia. En estas guías se actualiza el conocimiento respecto al diagnóstico y abordaje de las complicaciones relacionadas con la hipercoagulabilidad en estos casos, así como la eficacia y seguridad de la terapia con diferentes esquemas de anticoagulación. Finalmente, se mencionarán recomendaciones en el manejo de la coagulación en el contexto de IHAC, descompensación hepática aguda y aspectos específicos relacionados al paciente en protocolo de trasplante hepático (TH). Abstract: Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients.These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

Background: Liver disease (LD) is a common pathology worldwide. Many patients remain asymptomatic and undiagnosed. Colorectal cancer (CRC) is a prevalent neoplasm and a leading cause of cancer-related deaths globally. Multiple studies suggest that inflammation in the liver could drive the initiation of colorectal cancer., Methods: This five-year (2018-2022) case-control study included 274 patients diagnosed with CRC and adenomas at a community hospital in Houston, Texas. Each patient's medical record was reviewed for pre-existing LD, including steatosis, cirrhosis, primary biliary cirrhosis, and Hepatitis B and C infections. This study aims to investigate the association between LD and CRC risk and assess differences by gender, race, and ethnicity. The study cohort comprised 124 (45.3%) women and 150 (54.7%) men. Data were compared and analyzed using a Chi-squared test for independence and binomial logistic regression. A p-value of < 0.05 was considered statistically significant.  Results: Patients with LD had a two-fold increase in the odds of developing CRC compared to those without LD, in both univariate and multivariate analyses (OR 2.13 {95% CI 1.30-3.49}, p = 0.003 / OR 2.30 {95% CI 1.37-3.87}, p = 0.002, respectively). The chi-square test revealed that the association between CRC and LD was stronger in women than in men (p = 0.018 and p = 0.056, respectively)., Conclusion: Our study establishes a positive correlation between LD and CRC development, suggesting LD is a potential risk factor for CRC, particularly in women. Future research directions include exploring the underlying mechanisms of this association, evaluating the utility of early CRC screening in individuals with LD, and assessing the impact of interventions targeting LD on CRC incidence and mortality., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Research Institute Committee, Houston Methodist Willowbrook Hospital issued approval PRO00037701. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Aillaud-De-Uriarte et al.)