The coagulation system of healthy individuals has evolved to maintain a secure balance of pro- and antihemostatic systems. This fine-tuned balance promotes rapid coagulation during vessel breach, yet simultaneously preserves local control of thrombosis during vascular remodeling.1 Patients with cirrhosis acquire a unique global alteration in the coagulation and fibrinolytic system (Figure 1).2,3 As patients with cirrhosis develop progressive hepatic decompensation, coagulation protein synthesis is affected, thrombocytopenia worsens, and venous collaterals expand with portal hypertension.