Hemonc Q

[MudPhud20XX]

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A 57 yr old man with a long hx of heavy alcohol consumption comes to his doctor b/c he has been noticing large amounts of bright red blood in his stool. He says that he notices the bleeding primarily after defecation, but that he continues to see blood in his underwear throughout the day. He also complains that he is bruising more easily. He notes that he has been putting on weight, especially around his abdomen, although he has not changed his diet. Low levels of which of the following proteins are likely responsible for the pt's bleeding?

A. aspartate aminotransferase
B. factor VII
C. factor VIII
D. factor XII
E. Protein C

 

[Silverish]

B. Factor 7 isn't being made. Think alcohol --> pancreatitis --> fat malabsorption --> vitamin K deficiency. Factors 2,7, 9, 10 problems.

 

[MudPhud20XX]

So factor 8 and 12 are not made in the liver?

 

[Chilladosis]

Goljan Rapid Review 3rd edition pg 261: "cirrhosis leads to decreased activation of Vitamin K and synthesis of Vit K dependent cofactors...Clinical Findings associated with Vit K deficiency...Gastrointestinal bleeding"

As Silverish mentioned, "Vit k-dependent factors '2,7,9,10 protein c, and s' are synthesized in the liver as nonfunctional precursor proteins. liver epoxide reductase activates vitamin K (which was synthesized by colonic bacteria) Activated vit K gamma-carboxylates (aka activates) the vit k-dependent factors i.e. 2,7,9,10 and protein c and s." Goljan Rapid Review 3rd edition pg 253.

Therefore, the liver cirrhosis can be a two fold problem with the GI bleeding: 1) not producing the coagulation factor and 2) the activated form of vitamin K to activate the coag factors --> bleeding...and in this case GI bleeding.

 

[Silverish]

Its not the liver thats the problem there.
Vitamin K isn't being absorbed. Thats the problem.
An absence of Vitamin K leads to factors 2,7,9,10 deficiencies.

 

[Chilladosis]

question...how do you differentiate an vit k absorption/pancreatitis issue vs. liver cirrhosis in an alcoholic?

so the question asks what levels are low...
therefore, since 2,7,9,10 made in the liver as a non functional precursor protein....possible liver cirrhosis...not making those factors lead to the observed low levels.

What would the levels be in someone with pancreatitis? does vitamin k dictate the synthesis of those factors? From what I am reading, it seems vit k only gamma carboxylates those factors, thus making the nonfunctional synthesized factors now functional?

basically, i am wondering if it is site of synthesis (liver) or liver coag factor activator (vit k) is the main reason why we see low levels of factor 7.

the weight issue around the abdomen...is that cirrhosis or pancreatitits?

thanks for help clarifying...

 

[Silverish]

@Chilladosis I was replying to @MudPhud20XX
It could definitely be both. But for the sake of this question - if it were the liver, they would all be decreased levels of all coagulation factors.
When they're asking you for a specific factor after alcohol abuse over a period of time, think of Vitamin K def.

 

[Chilladosis]

awesome man, just trying to put the big picture together.

thanks for your help!