A 55-year-old man with chronic alcohol abuse underwent right-sided hemicolectomy for complicated diverticulitis 10 days ago. During his hospitalization, he developed abdominal wall hematomas at subcutaneous heparin injection sites. His preoperative laboratory blood work showed a hemoglobin of 5.4 g/dL, platelets of 87,000/µL, and normal coagulation parameters. The patient received 8 units of packed red blood cells during the perioperative period. His hospital course has been complicated by an abdominal wound infection and alcohol withdrawal symptoms.
His temperature is 38.1 C (100.6 F) , blood pressure is 98/56 mm Hg, and pulse is 108/min. His body mass index is 18 kg/m². The lungs are clear to auscultation and no murmurs are appreciated. The incision site is erythematous and tender. The patient has a palpable spleen tip. There is no evidence of active mucosal bleeding. His mental status is normal.
Laboratory results are as follows:

Factor V and VIII levels are normal, and factor VII level is decreased.
Which of the following is the most likely cause of this patient's coagulopathy?

Question

A 55-year-old man with chronic alcohol abuse underwent right-sided hemicolectomy for complicated diverticulitis 10 days ago. During his hospitalization, he developed abdominal wall hematomas at subcutaneous heparin injection sites. His preoperative laboratory blood work showed a hemoglobin of 5.4 g/dL, platelets of 87,000/µL, and normal coagulation parameters. The patient received 8 units of packed red blood cells during the perioperative period. His hospital course has been complicated by an abdominal wound infection and alcohol withdrawal symptoms.
His temperature is 38.1 C (100.6 F) , blood pressure is 98/56 mm Hg, and pulse is 108/min. His body mass index is 18 kg/m². The lungs are clear to auscultation and no murmurs are appreciated. The incision site is erythematous and tender. The patient has a palpable spleen tip. There is no evidence of active mucosal bleeding. His mental status is normal.
Laboratory results are as follows:

Factor V and VIII levels are normal, and factor VII level is decreased.
Which of the following is the most likely cause of this patient's coagulopathy?

Quizplus · Accepted Answer

This patient with chronic alcohol abuse, who likely has had nothing by mouth and is receiving antibiotics, has abnormal coagulation studies consistent with vitamin K deficiency. Vitamin K is rarely deficient in healthy individuals as it is widely available in a balanced diet and easily recycled by cells. Deficiency occurs more commonly in patients receiving prolonged total parenteral nutrition or antibiotics, alcoholics, malnourished patients, and those with fat malabsorption syndromes (eg, cystic fibrosis, primary biliary cirrhosis, celiac disease, inflammatory bowel disease). Mild vitamin K deficiency affects primarily factor VII and usually prolongs the prothrombin time (PT) and International Normalized Ratio. Severe deficiency affects the other vitamin K-dependent factors (II, IX, and X) in the coagulation cascade and prolongs both partial thromboplastin time (PTT) and PT. coagulation cascade (Choice A) Antiphospholipid syndrome presents clinically as recurrent arterial or venous thrombosis and/or fetal loss (antiphospholipid syndrome). PTT is prolonged and PT is normal. This patient's normal preoperative coagulation studies make antiphospholipid syndrome unlikely. (Choice B) Disseminated intravascular coagulation (DIC) presents as a consumptive coagulopathy with thrombosis and/or bleeding in the setting of trauma, obstetric complications, cancer, or surgery. Although PT and PTT are prolonged, the consumptive process results in low factor VIII and fibrinogen levels (although fibrinogen can be normal as it is an acute phase reactant). Low factor VIII levels can also help diagnose superimposed DIC in patients with underlying liver failure, in which factor VIII levels are usually significantly increased. (Choice C) Folic acid deficiency causes megaloblastic anemia. Patients often present with cheilosis, glossitis, fatigue, and gastrointestinal complaints (eg, diarrhea). (Choice D) Acute liver failure is characterized by elevated liver transaminases and encephalopathy. Coagulopathy due to liver parenchymal disease is associated with low levels of factor V and VII, while vitamin K deficiency will reduce factor VII but does not affect factor V. Educational objective: Vitamin K deficiency causes a coagulopathy with a prolonged prothrombin time and partial thromboplastin time (PT >> PTT). Vitamin K deficiency initially lowers factor VII levels, and may later affect II, IX and X. Liver parenchymal disease lowers factor V and VII levels. Factor VIII levels are decreased in disseminated intravascular coagulation but significantly increased or normal in liver failure. __________ References: Vitamin K in parenteral nutrition. (http://www.ncbi.nlm.nih.gov/pubmed/19874942)

A 55-Year-Old Man with Chronic Alcohol Abuse Underwent Right-Sided Hemicolectomy