Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Vitamin K deficiency and coagulopathy of liver disease
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Major bleeding with impaired hepatic haemostasis
Haemodynamic compromise, haematemesis, melaena, intracranial symptoms, postpartum or postoperative haemorrhage and rapidly falling haemoglobin require immediate source control whether the INR reflects vitamin K deficiency, anticoagulation or liver failure.
Action: Use ABCDE, activate the appropriate major-haemorrhage and urgent endoscopy, surgery or interventional pathway, obtain FBC, PT, APTT, fibrinogen, renal and liver tests and crossmatch, give slow intravenous phytomenadione when deficiency or VKA effect is plausible, and select PCC, plasma, platelets or fibrinogen only for a defined bleeding or reversal indication with specialist input.
Synopsis
Differentiate correctable vitamin K deficiency from the rebalanced haemostasis of liver disease, investigate bleeding by phenotype, and use vitamin K, components or anticoagulation without treating INR as a complete measure of risk.
Vitamin K deficiency typically prolongs PT first because factor VII has the shortest half-life; severe deficiency can prolong both PT and APTT and cause mucosal, gastrointestinal, operative or intracranial bleeding.
First-line assessment is medication and nutrition history, FBC and film, PT, APTT, fibrinogen, renal and liver profiles, bilirubin pattern and evaluation for cholestasis, malabsorption, antibiotics, warfarin, DIC and active bleeding.
A prompt PT improvement after phytomenadione supports deficiency, whereas non-correction suggests hepatocellular failure, ongoing VKA effect, consumption or another defect; do not delay emergency haemostasis to use this as a diagnostic test.
Key red flags
Haematemesis or melaena with cirrhosis is a portal-hypertensive emergency until endoscopy establishes the source; correcting INR must not delay vasoactive therapy, antibiotics and endoscopic haemostasis.
Acute liver failure
New encephalopathy with jaundice, coagulopathy, hypoglycaemia or lactate elevation needs urgent liver-centre and critical-care escalation.
Investigation priorities
01
First-line: FBC, PT, APTT and fibrinogenFirst stepFirst line
Define the pattern, consequences and possible consumption alongside clinical bleeding.
02
First-line: liver, renal and nutritional assessmentFirst line
Separate impaired synthesis from malabsorption and identify modifiers of bleeding and medicine clearance.
Management branches
Prolonged PTSeparate deficiency, drug and liver disease
PT or INR is newly prolonged with or without bleeding.
Verify sampling, review warfarin and interacting medicines, nutrition, antibiotics, diarrhoea, cholestasis, alcohol and known hepatic disease.
Check FBC, film, APTT, fibrinogen, liver and renal profiles and D-dimer when DIC is clinically plausible.
Key medicines
PhytomenadioneFor severe or life-threatening VKA-related haemorrhage, give 5–10 mg by slow intravenous injection with four-factor PCC; for non-emergency deficiency, choose an oral or intravenous dose from the current BNF or product protocol according to absorption and urgency, then recheck PT.
Four-factor prothrombin-complex concentrateFor Beriplex urgent VKA reversal, dose factor IX units/kg by pretreatment INR with weight capped at 100 kg: INR 2.0–3.9, 25 units/kg; INR 4.0–6.0, 35 units/kg; INR above 6.0, 50 units/kg; give vitamin K concurrently.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.