CORRELATION OF PLATELET COUNT WITH ESOPHAGEAL

VARICEAL HEMORRHAGE DURING LIGATION IN HEPATIC

CIRRHOSIS PATIENTS

Masriyania, Sinta Murtib, Danialc

aMedicalEducation Study Program, Mulawarman University Medical School

bInternal
Medicine Laboratory, Faculty of Medicine, Mulawarman University
cAnatomical Science Laboratory, Faculty of Medicine, Mulawarman University

Correspondence: masriyani.410@gmail.com

Abstract

Esophageal variceal bleeding is a disease that frequently occurs in patients with hepatic cirrhosis. Endoscopic ligation
procedure was primary perfomed for esophageal varices. Liver function abnormalities in cirrhosis cause disorder and
resulting a decrease in platelet count. The Limitations of platelet counts for endoscopy are obstacles when the procedure will
be performed. The purpose of this study was to determine the correlation between platelet count with variceal hemorrhage
during ligation in hepatic cirrhosis patients. The study was retrospective analytic with a cross sectional approach using
purposive sampling and patient secondary data. Data analysis using Chi Square test (Fisher Exact Test). The results showed
that p = 0.604> 0.05 so that there was no correlation between platelet counts in patients with hepatic cirrhosis at Abdul
Wahab Sjahranie Hospital Samarinda.

Keywords: Platelet count, variceal bleeding, esophageal varices

INTRODUCTION recurrent bleeding.8 Prevention of bleeding can be done

Based on the World Health Organization
(2008), cirrhosis of the liver disease was ranked 18th in
the world as the cause of death with the number of deaths
of 800,000 cases in 2004.1 Whereas in Indonesia
according to WHO (2018), the number of cirrhosis from
2000-2016 was recorded as many as 26.9 million
patients.2 Cirrhosis has several complications, but one
that often occurs is esophageal varices.3 Data from World
Gastroenterology Organization (2014), patients with
hepatic cirrhosis accompanied by esophageal varices
complications in the world increased from 30% to 70%
in 2013.4 Bleeding caused by esophageal varices is the
leading cause of death in patients with liver cirrhosis.5
Some risk factors for varices bleeding in cirrhotic
patients are platelet count <50,000 / µL, INR >1.5, high
HVPG, and the presence of stigmata bleeding in varices
veins.6.7 According to the American Society for
Gastrointestinal Endoscopy (2014), varices ligation is a
by using non-beta beta blockers or with varices ligation.9
Hepatic cirrhosis is a disease that can cause
liver function failure, so it can cause abnormalities in the
hemostasis system.10 Research of Mutual Education in
Tambunan11, hemostasis abnormalities were 78.57% in
patients with liver cirrhosis and 65.55% had clinical
manifestations of bleeding. The mechanism of
hemostasis abnormalities in liver disease is
thrombocytopenia.10 The incidence of thrombocytopenia
is less in western countries, with 13 cases (10.83%) of
120 cases of liver cirrhosis. Different in Indonesia with
the frequency of thrombocytopenia in liver cirrhosis is
quite high at 37-77%. This difference is probably due to
the different causes of liver cirrhosis, namely in the
western countries due to alcohol and in Indonesia caused
mostly by viral hepatitis infection.11
According to the Jing Li study7 of 874 cirrhotic

major endoscopic procedure in stopping acute and patients, 204 patients had severe thrombocytopenia, and
10 had bleeding. Whereas for 670 patients without severe
thrombocytopenia 11 patients were declared to have
bleeding. Although there were no provisions and further
studies, some researchers determined that patients
carrying out endoscopic procedures should have a
platelet count >50,000 / µL.13
The high rate of thrombocytopenia in cirrhosis
patients in Indonesia. As well as the imposition of
platelet count to be able to do endoscopy, it becomes an
obstacle when trying to carry out varices ligation. This
made the researchers interested in carrying out the
research with the title "correlation of platelet count to the
incidence of bleeding during esophageal varices ligation
in patients with hepatic cirrhosis at the Abdul Wahab
Sjahranie Hospital in Samarinda".
Hospital in 2018. Data analysis used Chi Square test
(Fisher Exact Test).
RESULTS AND DISCUSSION
This study was conducted in cirrhosis patients who were
hospitalized and carried out esophageal varicose ligation
in the endoscopic building. Patients with cirrhosis in
2018 were 137 patients, but only 62 patients with
cirrhosis of esophageal varices matched the inclusion
criteria of the researchers.

RESEARCH METHODS
The design of this study was a retrospective
analytic with cross sectional approach using purposive
sampling. The study sample in this study was patient
secondary data with hepatic cirrhosis who had undergone
a varices ligation procedure in Abdul Wahab Sjahranie

Table 1. Characteristics of Patients with Hepatic Cirrhosis Performing Esophageal Varices Ligation in Abdul Wahab
Sjahranie Hospital Samarinda

Characteristics (n) (%) Average Min. Max

Age (years) Total 62 100 49.71 32 76

Gender Male 44 71.0

Female 18 29.0

<1 40 64.5 7 days 1 day 25 days

Length of stay (weeks) >1-2 18 29.0
>2-3 2 3.2
>3 2 3.2

Size Esophageal Varices/EV Large EV 52 83.9

Medium EV 5 8.1
Small EV 5 8.1

Hemoglobin count / Hb (g / dL) Low Hb 55 88.7 9.7 3.7 15.9

Normal Hb 7 11.3

<50,000 6 9.7 116,000 29,000 507,000

Platelet Count (/ µL) 50,000-100,000 28 45,2
>100,000-150,000 14 22,6
>150,000 14 22,6

HbsAg Reactive 35 56,5

Non reactive 27 43,5

Child Pugh A 26 41,9

B 24 38.7
C 12 19.4

Bleeding Yes 25 40.3

No 37 59.7
 Table 2. Cross Tabulation of Platelet Count with
Incidence of Bleeding during Ligation of Esophageal
Varices
Incidence of
Bleeding during
Platelet
Ligation p R
(µ / L)
Bleedi No
ng bleeding
<50,000 3 6
50,000-100,000 11 26
- Society for Gastrointestinal Endoscopy 2015, for upper
>100,000-150,000 7 10 0,604 0.131
150,000 8 9
29 51
Total
80 patients
Correlation Between Platelet Count And The Incidence
of Bleeding During Esophageal Varices Ligation in
Patients with Hepatic Cirrhosis
Table 2. The results of an analysis of the correlation
between platelet count and the incidence of bleeding
during esophageal varices ligation show that the p count
is 0.604 more than 0.05. These results prove that the first
hypothesis is rejected, meaning that there is no
correlation between platelet count and the incidence of
bleeding during esophageal varices ligation in patients
with hepatic cirrhosis at Abdul Wahab Hospital Sjahranie
Samarinda. The correlation of -0.131 shows that the
lower platelet count, the higher the incidence of bleeding,
although the difference is not significant.
The researchers also justified platelet count
based on Child Pugh and the patient's varices size and
were seen to be related to bleeding events. The results
obtained bydegree Child Pugh and varices size did not
affect the results of the study.
This research is in line with research Ramos
GP, Binder M, Hampel P, et al13, who conducted a
retrospective study, sampled 144 patients with <50,000 /
µL platelet endoscopy for GI bleeding, 61% of patients
with cirrhosis. The results showed no side effects of
bleeding in patients who performed endoscopic actions
and the mortality rate was only 3%, so it was concluded
that the endoscopic action on thrombocytopenia proved
safe. The Qamar et al.study14 in America, patients with
hepatic cirrhosis accompanied by portal hypertension,
only had 1 bleeding patient from 41 patients with platelet
count <100,000 / µL. Femi et al15 in Nigeria stated that
of 199 patients who underwent endoscopic treatment, 83
cirrhotic patients who had varices veins and the results
after the ligation procedure did not record bleeding
episodes.
According to guidelines from the European
gastrointestinal bleeding there is no standard platelet
count that is considered a predictor of recurrent bleeding
or mortality and there is no evidence as a reference for
platelet transfusion.16 So far, it is not yet clear the
benefits of platelet transfusion in increasing platelet
counts and improving hemostatic function.17 The
mechanism of hemostasis disorders in cirrhotic patients
is due to a disruption of the synthesis and production of
procoagulant proteins, also accompanied by a disruption
of anticoagulant protein production, so that the impact of
spontaneous bleeding and clotting processes is relatively
balanced so the end result is not significant in hemostasis
disorders.18
CONCLUSION
From the results above, we can concluded that there is no
correlation between platelet count and the incidence of
bleeding during esophageal varices ligation in patients
with hepatic cirrhosis at Abdul Wahab Sjahranie Hospital
Samarinda.
REFERENCES
1. World Health Organization. 2008. The global burden
of disease: 2004 update. Geneva: WHO
2. World Health Organization. 2018. Global Health
Estimates 2016: Disease burden by Cause, Age, Sex,
by Country and by Region, 2000-2016. Geneva:
WHO
3. Lovena, A., Miro, S., & Efrida. (2017).
Characteristics of Patients with Hepatic Cirrhosis in
RSUP Dr. M. Djamil Padang. Andalas Health
Journal.
4. World Gastroenterology Organization. 2014. World
Gastroenterology Organization Global Guidelines:
Esophageal Varices. WGO Practice Guideline
5. Martínez, JD (2016). Prognostic Factors Associated
with Mortality in Cirrhotic Patients with Bleeding
Variables at Two Hospitals in Bogotá DC Colombia.
Rev Col Gastroenterol, 31

6. Tripathi, D., Stanley, AJ, Hayes, PC, & Patch, D.

(2015). UK guidelines on the management of
variceal haemorrhage in cirrhotic patients. Gut, 1-25.

7. Li, Jing et al. (2018). Association of coagulopathy

with the risk of bleeding after invasive procedures in
liver cirrhosis. Saudi Journal of Gastroenterology

8. Haq, Ihteshamul., Tripathi, Dhiraj. 2017. Recent

advances in the management of variceal bleeding.
Gastroenterology Report, 5 (2), 113–126

9. Soultati, A., Alexopoulou, A., & Dourakis, SP

(2006). New Developments in Thrombohemostatic
Disease. (V. Wiwanitkit, Ed.) New York: Nova
Science Publisher.

10. Mitchell, O., Feldman, DM, Diakow, M., & Sigal,

SH (2016). The pathophysiology of
thrombocytopenia in chronic liver disease. Hepatic
Medicine: Evidence and Research, 39-50.

11. Tambunan, Karmel L. (2015). Hemostasis Disorders

in Liver Cirrhosis. In S. Setiati, I. Alwi, AW Sudoyo,
MS K, B. Setiyohadi, & AF Syam, Textbook:
Internal Medicine. Jakarta: Interna Publishing.

12. Ross, William A. 2015. Advances in Endoscopy:

Endoscopic Interventions in Patients with
Thrombocytopenia. Gastroenterology and
Hepatology. vol 11

13. Ramos, Guilherme P et al. 2018. Outcomes of

Endoscopic Intervention for Overt Gastrointestinal
Bleeding in Severe Thrombocytopenia.
Gastrointestinal Endoscopy

14. Qamar, AA (2008). Platelet Count Is Not A Predictor

Of The Presence Or Development Of
Gastroesophageal Varices In Cirrhosis. Hepatology.

15. Femi, AA, Ior, AG, & Danjuma, PS (2016).

Endoscopic Varice Band Ligation: A Safe Way to
Treat. Clinical Medicine Research, 35-38.

16. Peck-Radosavljevic, M. (2017). Thrombocytopenia

in chronic liver disease. Liver International, 778–
793.

17. Laine, Loren. 2018. Treatment of Thrombocytopenic

Patients with GI Bleeding. In the American Society
for Gastrointestinal Endoscopy. Gastrointestinal
Endoscopy vol. 88 no. 1

18. Northup, PG, & Caldwell, SH (2013). Coagulation in

Liver Disease: A Guide for the Clinician. Clinical
Gastroenterology And Hepatology, 1064-1074.