**2.4 The prevalence of deep vein thrombosis in liver disease**

Deep vein thromboses in the lower extremity are common in the general medicine population without liver disease and range from 4% to 12% in inpatients (Anderson et al., 1991, Stein et al., 2002). Patients with cirrhosis share many of the same risk factors as hospitalized general medicine inpatients, including prolonged immobility, obesity, recent surgical procedures and malignancies. The presence of anticardiolipin and antiphospholipid antibodies have also been documented in patients with cirrhosis (Violi et al., 1994) and hepatitis C (Prieto et al., 1996). Hyperfibrinolysis, perhaps related to persistence of tissue plasminogen activator, is also prevalent in decompensated cirrhosis (Gunawan et al., 2006). It is not commonly symptomatic that DVT events may occur in patients with liver cirrhosis despite the coagulopathy of liver disease and clinical experience suggests this is the case. Several studies have shown lower levels of antithrombin, protein C and protein S in cirrhosis patients compared with controls (Mammen EF et al., 1992, De Caterina et al., 1993, Vukovich et al., 1995, Walker et al., 1990, Zurborn et al., 1988). Indeed, the diminution in the circulating levels of these inhibitors was noted in the early stages of liver disease and well before the setting of its chronic stages as in liver cirrhosis (Al-Ghumlas et., 2005, Abdo et al., 2010),

The literature is sparse in the area of clinical DVT in cirrhosis and is limited to case reports and a single case-controlled study (Ben Ari et al., 1997) comparing hospitalized cirrhotic patients with and without DVT. In this retrospective study, a new DVT or PE was diagnosed in appropriately 0.5% of all inpatients with documented cirrhosis despite 21% of these patients being on some form of DVT prophylaxis. While the rate of VTE is lower than expected in the general medicine population, these data show that patients with liver cirrhosis are not immune to VTE. It is plausible that this underestimates its true incidence. This could be explained as symptoms of VTE in the decompensated liver cirrhosis patients, particularly edema and dyspnea are common and not specific. Diagnosis requires a high index of suspicion and accurate radiologic testing methods.

#### **2.5 Clinical presentation**

The symptoms of DVT in the decompensated cirrhotic patient, edema, and dyspnea are common and not specific; those patients have similar risk factors as medical inpatients. Patients with liver disease can present to medical services with complaints of leg edema, leg pain dyspnea, and abdominal pain.
