In the NICE guidance, fresh frozen plasma has been suggested as treatment for patients with upper gastrointestinal bleeding whose clotting screen is prolonged more than 1.5 times normal, even in the absence of massive bleeding [1]. This is a recommendation which does not have an evidence basis. Coagulation screen was initially devised to diagnose individuals with single coagulation factor deficiencies like haemophilia and not to identify those patients who might be at risk of bleeding. In patients with and without liver disease, who have abnormal clotting tests, the risk of bleeding is NOT any higher than any other individual, something which has been conclusively shown in studies of patients to include cirrhosis [2,3]. In these patients, bleeding is often due to varices or ulcers which are akin to having an open surgical wound. As stated elsewhere in the guidance, endoscopic measures should be the definitive management. Abnormal coagulation tests should not distract the health care professionals from urgent endoscopy. The wait for plasma transfusion for correcting these abnormalities may prove deleterious in these settings. It is time that we do away with the dogma that an abnormal clotting screen means high risk of bleeding [4].

1. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K; on behalf of the Guideline Development Group. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012 Jun 13;344:e3412.
2. Tripodi A, Salerno F, Chantarangkul V, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005;41:553-558.
3. Lisman T, Bongers TN, Adelmeijer J, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006;44:53-61
4. Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive

Competing interests: None declared