Thrombocytopenia in Cirrhosis: Symptoms, Causes, Diagnosis, Treatment.

Thrombocytopenia (low platelet count) is common in people with cirrhosis. It can be caused by many factors, including an enlarged spleen and decreased platelet production. Severe thrombocytopenia can increase the risk of serious bleeding.

Cirrhosis is a condition in which your liver becomes permanently scarred. According to the National Institute of Diabetes and Digestive and Kidney Diseases, about 1 in 400 adults in the United States has cirrhosis.

If you have cirrhosis, your liver doesn’t function as well as a healthy liver. This can have many effects, including thrombocytopenia, which is a low level of platelets. Thrombocytopenia can cause symptoms like easy bruising or bleeding.

Below, we’ll explore more about thrombocytopenia in liver cirrhosis. We’ll discuss what causes it, how it’s diagnosed and treated, and the complications that can happen.

What causes thrombocytopenia in liver cirrhosis?

Thrombocytopenia is common in people with chronic liver diseases, including cirrhosis. In fact, about 70% of people with cirrhosis have some level of thrombocytopenia.

There are several potential causes of thrombocytopenia in people with cirrhosis. Let’s look at these causes in more detail.

Enlarged spleen

Spleen enlargement can happen in cirrhosis, which can cause platelets to get stuck in the spleen instead of entering the bloodstream.

In people with chronic liver disease and very severe spleen enlargement, up to 90% of the body’s platelets may be in the spleen.

Portal hypertension, a complication of cirrhosis, is typically the cause of spleen enlargement. It happens when scar tissue disrupts blood flow in the liver and increases blood pressure in the portal vein, which carries blood to the liver from the stomach, intestines, pancreas, gallbladder, and spleen.

Reduced platelet production

Livers with cirrhosis may make lower levels of thrombopoietin, a protein that tells your bone marrow to make platelets. Because of this, fewer platelets are produced.

Other liver disease-related factors can also contribute to reduced platelet production in the bone marrow. These include the effects of chronic hepatitis B or hepatitis C infection as well as heavy alcohol consumption.

Increased platelet destruction

People with certain types of cirrhosis may also have increased destruction of platelets. This happens when your immune system mistakenly attacks platelets.

Immune-mediated platelet destruction can be caused by a preexisting autoimmune disease. Hepatitis C infection may also trigger immune-mediated platelet destruction.

How is thrombocytopenia due to liver cirrhosis diagnosed?

After taking your medical history and doing a physical exam, your doctor will likely order a complete blood count (CBC) and use the results of this blood test to diagnose thrombocytopenia.

A CBC is a common blood test that measures the levels of different blood cells, including platelets. It uses a blood sample collected from a vein in your arm.

If you haven’t been previously diagnosed with cirrhosis, your doctor may order other tests if they suspect you may have cirrhosis. These may include:

• liver function tests
• blood clotting tests
• metabolic panel
• tests for hepatitis B or hepatitis C
• tests for autoimmune conditions that can affect the liver
• imaging tests, such as ultrasound, CT scan, MRI scan, and liver elastography
• liver biopsy

How is thrombocytopenia due to liver cirrhosis treated?

There are several potential treatments for thrombocytopenia in liver cirrhosis, such as:

• Drugs that stimulate platelet production: There are several drugs that may be used to increase platelet production in the bone marrow. These include avatrombopag (Doptelet), eltrombopag (Promacta), lusutrombopag (Mulpleta), and romiplostim (Nplate).
• Platelet transfusion: During a platelet transfusion, you’ll receive new platelets from a healthy donor.
• Spleen removal: Removing the spleen (a procedure called splenectomy) can help prevent platelets from getting stuck in the spleen. This, in turn, may increase platelet count.
• Splenic artery embolization: This procedure can reduce the effects of portal hypertension by cutting off blood flow to an artery that goes to the spleen. It may be used as an alternative to spleen removal.
• Transjugular intrahepatic portosystemic shunt (TIPS): In TIPS, a doctor places a stent into a vein in your liver, which is then connected to your portal vein. This may help reduce blood pressure in your portal vein.

While the damage caused by cirrhosis is permanent, steps can be taken to help prevent it from getting worse. Some examples include:

• treating chronic hepatitis B or hepatitis C infections
• not drinking alcohol
• maintaining a moderate weight if you have nonalcoholic fatty liver disease (NAFLD)
• using immunosuppressant medications to treat autoimmune causes of cirrhosis
• avoiding medications that are hard on the liver

What are the complications of thrombocytopenia due to liver cirrhosis?

When platelet levels are lower than normal, your blood can’t clot as quickly. As such, the main complication of thrombocytopenia is serious bleeding.

Bleeding can happen externally, such as through a break in the skin due to a cut. It may also happen internally as well — for instance, after an injury or accident.

A complication of portal hypertension (high blood pressure in the portal vein) called varices can also cause internal bleeding. Varices are a type of varicose vein that form in the esophagus or stomach due to portal hypertension. Varices can burst and cause serious bleeding.

Having severe thrombocytopenia may also make managing cirrhosis and other health conditions more challenging. This is because of the risk of serious bleeding during or after a procedure or surgery is higher.

What is the outlook for thrombocytopenia due to liver cirrhosis?

Many people with cirrhosis have thrombocytopenia. However, mild to moderate thrombocytopenia typically doesn’t require treatment.

Severe thrombocytopenia, defined as fewer than 50,000 platelets per microliter of blood, increases the risk of serious bleeding. As mentioned above, severe thrombocytopenia can make managing cirrhosis and other conditions more difficult.

Thrombocytopenia generally indicates the presence of advanced disease. It’s also associated with a poorer outlook for cirrhosis and an increased risk of complications.

The bottom line

Thrombocytopenia is common in people with cirrhosis. It can be caused by many factors, including an enlarged spleen, decreased platelet production, and increased destruction of platelets.

Your doctor can use a blood test to see if your platelet levels are low. There are several potential treatments for thrombocytopenia in cirrhosis, such as medications, platelet transfusions, or procedures like spleen removal.