E-Mail karger@karger.com Review Digestion 2016;93:149–159 DOI: 10.1159/000442877 The Complex Role of Anticoagulation in Cirrhosis: An Updated Review of Where We Are and Where We Are Going Tawfik Khoury   a Abu Rmeileh Ayman   a Jonah Cohen   d Saleh Daher   b Chen Shmuel   c Meir Mizrahi   e a  Department of Medicine, b  Department of Gastroenterology and Hepatology, Department of Medicine, and c  Department of Cardiology, Hebrew University-Hadassah Medical Center, Ein-Kerem, Jerusalem, Israel; d  Division of Gastroenterology and Hepatology and e  Division of Gastroenterology and Hepatology, Advanced Endoscopy Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., USA population. Although traditionally, liver cirrhosis has been considered a disease with hypocoagulability state and in- creasing bleeding tendency due to severe homeostatic dis- ruption in liver disease, until recently there is increasing awareness and evidence that cirrhotic patients are not com- pletely protected from thrombotic events although they Key Words Cirrhosis · Anticoagulation · Venous thromboembolism Abstract Venous thromboembolism (VTE) in cirrhotic patients is an increasingly encountered problem in the daily clinical prac- tice; there is still a debate on the ideal measures to be fol- lowed for prophylaxis and treatment of VTE among this Received: August 6, 2015 Accepted: November 28, 2015 Published online: January 9, 2016 Tawfik Khoury, MD Department of Medicine Hebrew University-Hadassah Medical Center, PO Box 1200 Ein-Kerem, Jerusalem, IL 91120 (Israel) E-Mail tawfikkhoury1  @  hotmail.com, taufick  @  hadassah.org.il © 2016 S. Karger AG, Basel 0012–2823/16/0932–0149$39.50/0 www.karger.com/dig T.K. and A.R.A. contributed equally to this work. Key Points • Increasing evidence supports the hypercoagulability of CLD, and patients with cirrhosis are not natu- rally anticoagulated as has been historically believed. • Cirrhotic patients with PVT can be successfully treated with anticoagulation without excess bleeding risks and a study shows improved survival and decreased hepatic decompensation in the setting of treating such thrombosis. • To date, there are no well-established assays for correctly evaluating the hemostatic phenotype in cir- rhotic patients; however, recently several novel techniques are in experimental phases and may better estimate bleeding tendency. • Several anticoagulation drugs are available for clinical use including several new oral anticoagulants. Each drug has its own advantages and disadvantages. Still no consensus is available regarding the pre- ferred anticoagulant agents used in cirrhosis. • Overall, sufficient evidence exists, promoting the use of anticoagulation in cirrhotic patients for both VTE prophylaxis and treatment in carefully selected patients after consideration of pharmacologic or endoscopic variceal bleeding prophylaxis.