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John Abraham: Breaking the ‘Bleeding Disorder’ Myth About Cirrhosis and Coagulation
John Abraham/LinkedIn
Apr 1, 2026, 17:18

John Abraham: Breaking the ‘Bleeding Disorder’ Myth About Cirrhosis and Coagulation

John Abraham, Assistant Professor at Christian Medical College and Hospital, shared a post on Linkedin about a recent article by Conor Bell published in Journal of Thrombosis and Haemostasis, adding:

“Cirrhosis and Coagulation — Beyond the ‘Bleeding Disorder’ Myth

For years, we were taught that cirrhosis meant a bleeding tendency.
But evolving evidence tells a very different story.

Paper: Prevention and treatment of thrombosis in patients with decompensated cirrhosis
Journal: Journal of Thrombosis and Haemostasis (JTH), 2026
Authors: Conor Bell, Amber Afzal, Stephanie Carlin, Lara N. Roberts
DOI: 10.1016/j.jtha.2025.12.018

The Core Concept: Rebalanced Hemostasis

Cirrhosis leads to a ‘simultaneous decline in procoagulant and anticoagulant factors’, creating a fragile equilibrium—not a hypocoagulable state.

  • Decreased Factors II, V, VII, IX, X
  • Decreased Protein C, Protein S, Antithrombin
  • Increased von Willebrand factor
  • Decreased ADAMTS13

Net effect: A system that can tip toward bleeding or thrombosis

Why Conventional Thinking Fails

  • INR reflects only procoagulant deficiency and therefore overestimates bleeding risk
  • Platelet count does not capture compensatory mechanisms (increased vWF)
  • Standard labs isn’t true hemostatic balance

Mechanistic Insights

  • Endothelial activation creates a prothrombotic milieu
  • Platelet count is reduced but function relatively preserved
  • Fibrinolysis is dysregulated (both hyper and hypo states)
  • Portal hypertension is the major driver of bleeding

Clinical Reality

  • High Risk of stroke (AF)
  • High risk of VTE (2× risk)
  • High Risk of Portal vein thrombosis

At the same time:
Bleeding risk is real—but largely ‘portal hypertension–driven’, not purely coagulopathic

Take-Home Message

Cirrhosis is not a bleeding disorder.
It is a ”rebalanced but unstable’ hemostatic state’.

This paradigm shift is crucial when:

  • Deciding on anticoagulation
  • Interpreting INR/platelets
  • Managing PVT or AF

As clinicians, the challenge is no longer ‘Should we anticoagulate?’ but ‘Who, when, and how safely?’”

Title: Prevention and treatment of thrombosis in patients with decompensated cirrhosis

Authors: Conor Bell, Amber Afzal, Stephanie Carlin, Lara N. Roberts

Read the Full Article on Journal of Thrombosis and Haemostasis

John Abraham

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ADAMTS13 Amber Afzal antithrombin bleeding disorders Blood Cardiology Cirrhosis coagulation Coagulopathy Conor Bell Health Hematology Hemophilia Hemostasis Hemostasis News Hemostasis Today INR John Abraham Journal of Thrombosis and Haemostasis JTH Lara N. Roberts Medicine platelets portal hypertension protein C protein S Stephanie Carlin stroke thrombosis venous thromboembolism Von Willebrand Factor VTE VWD
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