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BMJ Case Reports 2008; doi:10.1136/bcr.06.2008.0008
  • Reminder of important clinical lesson

Iatrogenic vitamin K deficiency and life threatening coagulopathy

  1. Samuel John Ford,
  2. Alistair Webb,
  3. Richard Payne,
  4. Norbert Blesing
  1. Cheltenham General Hospital, General Surgery, Sandford Road, Cheltenham, GL537AN, UK
  1. samuelford{at}hotmail.co.uk
  • Published 20 November 2008

Summary

A man was admitted with abdominal pain. Treatment for acute diverticulitis was instituted with intravenous antibiotics and oral limitation. Imaging demonstrated a complex inflammatory mass. Prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen were within normal limits. However, repeat preoperative clotting studies demonstrated a severe unexpected coagulopathy to have developed since admission that could have caused fatal intraoperative exsanguination. Direct assays showed severe, isolated deficiency of vitamin K dependent clotting factors, and mixing studies normalised both the PT and APTT, ruling out a coagulation inhibitor. The coagulopathy responded to intravenous vitamin K administration. Dietary insufficiency underlies vitamin K deficiency in the presence of normal biliary and enteral function. A significant coagulopathy can result with additional eradication of intestinal microflora. Hypoprothombinaemia is recognised as a consequence of protracted treatment with broad spectrum antibiotics, and vigilance is required for those at risk. The development of such a rapid and unexpected coagulopathy posed a complex preoperative management issue delaying operative intervention; although avoided by fortuitous preoperative screening, it could have caused significant intraoperative bleeding. The remarkably specific lack of vitamin K dependent clotting factors strongly suggested a vitamin K deficiency and administration of coumarins was ruled out.

Footnotes

  • Competing interests: none.

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