Q: A friend of ours had a bad leg clot (DVT). What surprised me is that he has cirrhosis of the liver. I thought that people with cirrhosis have bleeding problems. Can you tell me how he could get a clot?
A: You're correct that folks who have severe cirrhotic liver damage have clotting problems due to an inability of a damaged liver to make adequate proteins necessary for proper clotting to occur, a decreased number of platelets (clot cells) and an impairment in the function of existing platelets. But we also occasionally see DVT leg clots and pulmonary embolisms (lung clots) due to a cirrhotic liver's decreased production of anti-clotting proteins. Here's why: the healthy liver makes some proteins that assist with clotting as well as regulatory proteins that squelch clotting pathways to keep the clotting process balanced. A cirrhotic, scarred liver lacks a normal clotting balance.
It's difficult for doctors to predict who is at risk for a serious clot. Simply looking at blood clotting tests like an increased prothrombin time (PT), an increased INR level or a low platelet count cannot assure us of a low risk of serious clots. We once thought folks with cirrhosis/end-stage liver disease were "auto-coagulated" (i.e. — protected against clots as though they were on a blood thinner like Coumadin), but as you've seen in your friend's situation, that's not the case.
Q: I've been hearing a lot about the U.S. Preventive Services Task Force making recommendations about the need for things like PSA blood tests and mammograms under a certain age. Who are they and what is their agenda?
A: The USPSTF is a quasi-governmental group of 16 experts in preventive and evidence-based medicine that operates under the auspices of the Agency for Healthcare Research and Quality. Their "good versus harmful," cost-conscious agenda is to make evidence-based recommendations on whether or not there's a need or benefit to many of the common clinical preventive services performed by doctors in the United States.
A number of their recommendations have been controversial. While they have made a number of good recommendations, some of their controversial ones include: (1) No routine screening for colorectal cancer for folks older than the age of 75; (2) No screening for testicular cancer in adolescents and adult males; (3) No PSA screening for prostate cancer; (4) No mammograms until age 50; (5) No routine use of aspirin to prevent colorectal cancer; (6) No routine EKGs in asymptomatic folks, and insufficient evidence to recommend for or against routine EKGs in folks at high cardiovascular risk; (7) Insufficient evidence to recommend for or against routine screening for glaucoma; (8) Insufficient evidence to recommend for or against routine screening for thyroid disease in adults; (9) No routine screening for peripheral arterial disease; and (10)B No value to teaching patients how to do a self-breast examination.
Dr. Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: "Ask Dr. H," P.O. Box 767787, Atlanta, Ga. 30076. Due to the large volume of mail received, personal replies are not possible.