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Protein-losing enteropathy — Clinical Guidelines

Overview

Protein-losing enteropathy (PLE) is a condition characterized by excessive loss of proteins through the gastrointestinal tract, leading to hypoproteinemia and associated complications such as coagulopathy and malnutrition. 2

Diagnosis

Clinical Presentation: Symptoms include edema, ascites, and hypoalbuminemia.

Laboratory Tests:

- Decreased serum albumin levels. - Elevated fecal alpha-1-antitrypsin clearance. - Prolonged prothrombin time (PT) or international normalized ratio (INR) indicating coagulopathy 3 14.

Coagulation Monitoring: Use of point-of-care (POC) devices for rapid assessment of coagulation parameters like INR and activated clotting time (ACT) 4 16.

Management

First-Line Treatments:

- Address underlying causes (e.g., surgical correction of malformation, discontinuation of causative medications). - Vitamin D supplementation in cases with hypovitaminosis D 2.

Adjunctive Treatments:

- Fresh frozen plasma (FFP) transfusions to correct coagulopathy, particularly in severe cases 13 20. - Monitoring and management of anticoagulation therapy to prevent exacerbations of coagulopathy 6 11. - Use of cryoprecipitate for severe coagulopathy, though its use varies by region 7.

Special Populations

Elderly: Increased risk of coagulopathy and medication interactions; careful monitoring of INR and vitamin K status 8 14.

Comorbidities: Patients with concurrent liver disease may require additional management for coagulopathy 13.

Key Recommendations

Monitor Coagulation Parameters: Regularly assess PT/INR using POC devices to guide management and prevent bleeding complications (Evidence: Moderate 3 4 16).

Correct Underlying Causes: Address and treat the root cause of PLE to halt protein loss (Evidence: Expert opinion 2).

Supplement Vitamin D: In cases of hypovitaminosis D, consider cholecalciferol supplementation to support overall health and potentially mitigate PLE symptoms (Evidence: Strong 2).

Utilize Fresh Frozen Plasma: For severe coagulopathy, consider FFP transfusions to correct coagulation abnormalities (Evidence: Moderate 13 20).

Manage Anticoagulant Therapy: Closely monitor and adjust anticoagulant therapy to prevent exacerbations of coagulopathy (Evidence: Moderate 6 11).

References

1 Tian X, Chen T, Lu L, Xie P, Wang D, He R et al.. Abnormal coagulation indicators associated with β-lactamantibacterial drug: a pharmacovigilance study based on the FAERS database. Naunyn-Schmiedeberg's archives of pharmacology 2026. link 2 Jablonski SA, Shropshire SB, Watson VE, Manchester AC, Cridge H, Lennon EM et al.. Treatment of Hypovitaminosis D With Cholecalciferol in Dogs With Protein-Losing Enteropathies: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial. Journal of veterinary internal medicine 2025. link 3 Wallisch WJ, Kidd B, Shen L, Hammer R, Siscel J. Coagulopathy and Emergent Reversal of Anticoagulation. Anesthesiology clinics 2023. link 4 Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J et al.. Point of care coagulation management in anesthesiology and critical care. Minerva anestesiologica 2022. link 5 Gilbert BW, Bissell BD, Santiago RD, Rech MA. Tracing the Lines: A Review of Viscoelastography for Emergency Medicine Clinicians. The Journal of emergency medicine 2020. link 6 Wychowski MK, Ruscio CI, Kouides PA, Sham RL. The scope and value of an anticoagulation stewardship program at a community teaching hospital. Journal of thrombosis and thrombolysis 2017. link 7 Blasi A, Beltran J, Pereira A, Puig L. The cryoprecipitate: that old unknown. Revista espanola de anestesiologia y reanimacion 2015. link 8 Takada H, Toru H, Bunya N, Kiriu N, Kato H, Koido Y et al.. Acquired absolute vitamin K deficiency in a patient undergoing warfarin therapy. The American journal of emergency medicine 2014. link 9 Nishiyama J, Matsuda M, Urimoto G, Sakamoto R, Ito K, Suzuki T. Applicability of a compact PT-INR measuring device CoaguChek XS to perioperative management. The Tokai journal of experimental and clinical medicine 2011. link 10 Launiainen T, Sajantila A, Rasanen I, Vuori E, Ojanperä I. Adverse interaction of warfarin and paracetamol: evidence from a post-mortem study. European journal of clinical pharmacology 2010. link 11 Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida AJ. Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs. Joint Commission journal on quality and patient safety 2010. link36032-6) 12 Doyle D. Thomas Addis of Edinburgh (1881-1949) and the coagulation cascade: 'for the greatest benefit done to practical medicine'. British journal of haematology 2006. link 13 Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results. American journal of clinical pathology 2006. link 14 Atreja A, El-Sameed YA, Jneid H, Hoogwerf BJ, Peacock WF. Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations. The American journal of emergency medicine 2005. link 15 Auble TE, Taylor DM, Hsu EB, Yealy DM. Evaluation of guidelines for ordering prothrombin and partial thromboplastin times. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2002. link 16 Hirsch J, Wendt T, Kuhly P, Schaffartzik W. Point-of-care testing apparatus. Measurement of coagulation. Anaesthesia 2001. link 17 Valentine S, Williamson P, Sutton D. Reduction of acute haemorrhage with aprotinin. Anaesthesia 1993. link 18 O'Donnell D. Hypoprothrombinaemia associated with use of cephamandole. The Australian and New Zealand journal of surgery 1991. link 19 Turnbull AD. The two stage tracheostomy as a safe technique in instances of severe coagulopathy. Surgery, gynecology & obstetrics 1991. link 20 McCarthy LJ. Fresh frozen plasma: past, present and future. Indiana medicine : the journal of the Indiana State Medical Association 1989. link 21 Korth MJ, Finn DJ, Gustafson GL. Use of a Western blotting technique in the purification of a cysteine proteinase inhibitor. Analytical biochemistry 1988. link90270-9) 22 Law H, Lingwood CA. Use of fluorescent standards in protein transfer and immunoblotting. Accurate estimation of the molecular weight of immunoreactive species. Analytical biochemistry 1985. link90590-1)

Protein-losing enteropathy