A study of coagulation profile in diseases of liver: At tertiary care center hospital

Introduction: The liver is the main site of organ for coagulation system. Liver plays a predominant role in regulation of hemostasis. Hepatic disorders are widely prevalent in tropical countries are responsible for morbidity and mortality. Aims and Objective: The diagnosis of liver diseases by assisting in differential diagnosis with various coagulation tests. In assessment of prognosis of patients of various liver disease. Materials and Methods: The study was conducted in the laboratory of Guru Gobind Singh Hospital, Jamnagar. This study included 100 patients clinically diagnosed with liver disease who were divided into three categories – cirrhosis, viral hepatitis, and obstructive jaundice. The coagulation tests PT, APTT, BT, CT, and platelet count were performed and the results were evaluated in groups. Result: Out of the 100 patients, 40 were diagnosed with cirrhosis, 40 were of viral hepatitis, and 20 were of obstructive jaundice. About 75% (75/100) had prolonged PT. About 39% (39/100) had prolonged APTT. Thrombocytopenia was seen in 58% (138/300) patients.17 cases out of 100 patients (17%) show result of Hypofibrinogenemia. Conclusion: The conclusion of this study reveals various coagulation abnormalities vary with different liver diseases, duration and severity of disorders. In advancing liver cirrhosis, raised level of PT and APTT indicates damage to liver parenchyma resulting in reduced production of coagulation proteins with increased risk of bleeding tendencies which can be detected before these ensue.


Introduction
Liver is an important organ of the body having functions of synthesis of plasma proteins and a range of blood clotting factors being produced, some of them exclusively in the organ. All of them are deranged in various liver disorders. 1 Liver plays a predominant role in the regulation of haemostasis. Both cellular and plasmatic coagulation are defective, representing a hallmark of advanced liver disease. 2 Laboratory tests, coagulation tests and liver function tests are useful in the evaluation, management and assessment of prognosis. They provide a sensitive, noninvasive method of screening for the presence of liver dysfunction. 3 Along with function of synthesis of protease inhibitors, liver also clears activated clotting factors from blood. Intravascular coagulation has been reported as frequently occurring in patients with acute liver failure. The resultant consumption coagulopathy complicates a pre-existing coagulation defect due to further depletion of fibrinogen, factor V and factor IX and X. 5 Considering above mentioned factors and importance of coagulation tests which is helpful in evaluation of various hepatic disorders, the present study is undertaken.
Aims and Objectives 1. The diagnosis of liver diseases by assisting in differential diagnosis with various coagulation tests. 2. In assessment of prognosis of patients of various liver disease. 3. In the prediction of response to treatment for liver disease.

Materials and Methods
The present study was conducted on 100 patients having liver disease attending Medicine and Paediatric clinics at tertiary care hospital. They were divided into following three groups: 40 cases of cirrhosis (Bleeders, Non bleeders), 40 cases of viral hepatitis and 20 cases of Obstructive jaundice.
Blood samples from the patients were collected and following coagulation tests were performed. 1. Bleeding time-Ivy's Method 2. Clotting time-Lee an White Method 3. Platelet count-By automated haematology analyzer.
(Cell Dyn 3700). 4. Prothrombin time-By reagent kit Lyoplastinmanufactured by Tulip diagnostic ltd. 5. Activated Partial Thromboplastin time-By diagnostic kit manufactured by Diagnostica Stago S.A.S. 6. Plasma fibrinogen estimation--By diagnostic kit manufactured by Diagnostica Stago S.A.S. The clinical history and data of patients liver disease were correlated and results were recorded. Inclusion Criteria: Criterion of inclusion was presence of liver disease including cirrhosis, viral hepatitis, obstructive jaundice. All patients of both sexes, age ranging from 20 to 70 years and irrespective of socioeconomic status, were included. Exclusion Criteria: Patients with previous history of coagulation disorders or who took any of the following drugs in the previous week were excluded: aspirin or nonsteroidal anti-infl ammatory drugs, antihistaminics, penicillin, sulfonamides, beta blockers, and anticoagulants.

Result
A study of 100 cases in various liver diseases was carried out for various coagulation tests like, bleeding time(BT), Cotting time(CT), Prothromin time(PT), Activated partial Thromboplastin time, Plasma fibrinogen and platelet count at Department of pathology during period of June 2005 to October 2006.
Various observations and results were taken and studies in table form. Table 1 shows bleeding time, clotting time, prothrombin time, activated partial thromboplastin time, fibrinogen level in patients with various liver diseases.

Discussion
One hundred patients of various liver diseases with various clinical manifestations studied for coagulation abnormalities by doing coagulation tests like bleeding time, platelet count, fibrinogen estimation and prothrombin time and activated partial prothrombin time. With this other normal 25 persons also studied for control.
The results obtained are tabulated and compared with those of previously published studies in various years and similar work of well-known workers in this field. Table 2 shows, in cirrhosis, the bleeding time in both bleeders and non bleeders is within normal range, as shown by present study and other worker's study. But the mean value for bleeders is quite higher than non bleeders as shown by Poonam Rastogi 9 et al in 18 cases and present study in 20 cases. So this values are quite comparable in present study with study of Poonam Rastogi et al. 9 In viral hepatitis, 40 cases show range of 140+ 25 sec which is normal range and similar observations was made by Ratnoff et al 7 and Donaldson et al and Singh et al. 8 In obstructive jaundice, bleeding time is comparable with those of other studies. In Viral hepatitis, present study show elevation of PT which is comparable with study of S. Gurdoy et al. 12 In Obstructuve jaundice, all 20 cases(100%) show elevation in our study. Overall results and present study of PT are quite comparable with other worker's results in all liver diseases. Table 5 shows in cirrhosis, in present study shows elevation in aPTT in 16 cases (80%) in bleeders in range of 44.6+ 4.6 and 20 cases (15%) in non bleeders with range of 35.8+ 5.8 which is comparable with other study.
In viral hepatitis 22.5% cases show elevation in aPTT by present study. Similar observations were made by above mentioned authors in their studies.
In obstructive jaundice, 55% cases show prolongation of aPTT by present study. No other worker has done similar study. As per above results observed by present study showing elevation value of APTT which is quite comparable with the other results. Table 6 shows study of fibrinogen in liver disease by comparison of other workers with present study.in cirrhosis, observations show hypofibrigenemia in Norber's study and present study which is quite comparable. The minor variation of results may be due to different number of cases studied and population difference of patients studied.
In viral hepatitis observations show hypofibrigenemia which is comparable with other studies.
In obstructive jaundice. Present study 20 cases studied with results in range of 230+ 30 mg% is seen which is in normal range. No other workers have done similar study in obstructive jaundice Hypofibrigenemia in bleeders noted by all workers are almost similar with present study. Same observations are seen in non bleeders cases.

Conclusion
Present study of 100 cases of various liver diseases for various coagulation tests was done. Efforts were made to find out the importance and diagnostic significance of various coagulation tests in various liver diseases. The following conclusions were made.

Bleeding Time and Clotting Time:
In cirrhosis of liver, BT and CT show normal range but mean value for bleeders is higher than non bleeders. In viral hepatitis and obstructive jaundice, BT and CT shows normal range. Prothrombin Time: Prothrombin time shows marked significant value in all liver diseases. In cirrhosis bleeder shows elevation of Prothrombin time in 90-100% cases and non bleeders show 50-55 % cases.
In viral hepatitis, PT value is elevated in 75% cases. In obstructive jaundice, 80% cases show rise in PT. Activated Partial Thromboplastin Time: aPTT is quite significant in cirrhosis. Bleeders show elevation of aPTT in 80% cases and non bleeders show 15% cases. In viral hepatitis, decreased number of cases i.e.22.5% rise in aPTT. In obstructive jaundice, moderate number of cases i.e. 55% cases show rise in aPTT.

Fibrinogen
Hypofibrinogenemia Observed: In cirrhosis, bleeders show moderate to severe degree of hypofibrigenemia in 55% cases. Non bleeders show moderate degree of hypofibrigenemia in 25% cases.
In viral hepatitis and obstructive jaundice mild degree of hypofibrigenemia is seen i.e. 2.5% cases it suggests fibrinogen has not much significant value in viral hepatitis and obstructive jaundice.

Conflict of Interest:
None.