Excessive fibrinolysis that threatens clot integrity
is known as hyperfibrinolysis.41 Abnormal fibrinolytic
activity may be overlooked as a cause of
bleeding, particularly in liver disease, and the
condition is difficult to diagnose because of the
absence of a specific routine assay. Clinical suspicion
should be high in cases in which bleeding
continues despite hemostatic replacement therapy,
platelet levels are relatively conserved but fibrinogen
levels are disproportionately low, and d-dimer
levels are disproportionately high for disseminated
intravascular coagulation. Thromboelastography,
which may help differentiate fibrinolytic activation
from coagulation factor deficiency, is a
crude tool, since it detects only the most marked
changes.42 Fibrinolytic bleeding should be considered
particularly in patients with liver disease
and disseminated cancers. The use of tranexamic
acid, either by infusion or orally (depending on
the severity of the problem and the state of the
patient), is beneficial in controlling bleeding.