Balancing bleeding and thrombosis in chronic liver disease: ROTEM-guided management of life-threatening lower GI bleed

Chronic liver disease (CLD) often presents with unique coagulation challenges that complicate management of gastrointestinal bleeding. Conventional laboratory tests (PT, aPTT, INR) are often unreliable in predicting the true balance between bleeding and thrombotic risk in CLD. Also, the occurrence of meckel’s diverticulum-related bleeding in adults is an uncommon phenomenon. A 28-year-old male with chronic liver disease presented with life-threatening gastrointestinal bleeding and hemorrhagic shock. Rotational thromboelastometry (ROTEM) used as a point-of-care test, revealed factor deficiency with preserved platelet function. ROTEM-guided transfusion strategy included fresh frozen plasma and PRBCs. Contrast enhanced computed tomography (CECT) abdomen demonstrated small bowel obstruction with intraluminal bleeding. Emergency exploratory laparotomy revealed a bleeding Meckel's diverticulum, which is rare in adults. Segmental resection, including the diverticulum, was performed with creation of double-barrel ileostomy. Managing bleeding in chronic liver disease is challenging, as it requires controlling bleeding while carefully avoiding an increased risk of thrombosis. ROTEM- by offering a dynamic, whole-blood picture of coagulation, allows for tailored transfusion strategies, avoiding unnecessary correction and associated thrombotic risk while at the same time, facilitating a definitive surgery for bleeding Meckel’s diverticulum.