Bleeding and colonoscopic polypectomy

1. Colonoscopic Polypectomy Is it safer to cease or continue anticoagulation ? Prince of Wales Journal Club October 9th 2006 Christopher Reitz Mentor: Dr. A. Matthews

Pioneered by Wolff and Shinya in 1973

Replaced surgical removal

Safer than surgery(In 70s assoc. with 14% morb.and 5% mort.)

Frequency of clin. evident bleeding in CP 0.2%-1.0%

Waye J. Colonoscopy. CA Cancer J Clin

1992;42:350-65

Increasing use of colonoscopy

(screening for neoplasms in elderly patients with multiple comorbidities)

Some require Tx with Aspirin, Warfarin, or NSAIDsEffect on platelet function or on clotting factors

1. increase risk of post-polypectomy bleeding

2. Probability of thromboembolic complication following reversal or discontinuation of anitcoag. (Depends on preexisting condition)

Mechanical heart valves

Risk Mitral >Aortic

No therapy: 4 per 100 patients per year

On Antiplatelet: 2.2 per 100 patients per year

On Warfarin: 1 per 100 patients per year

Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prosthesis. Circulation 1994;89:635-41.

Artrial fibrillation

No therapy: 5 per 100 patients per year

Increased Risk with assoc. Cardiomyopathy, Valvular heart disease, or recent thromboembolic event.

Laupacis A. et al.Antithrombotic therapy in atrial fibrillation Chest 1992;102:426s-33s

Early cessation of anticoagulation for a short time does not increase the risk of PE

Better delay procedure > 6 month

Research Committee of the British Thoracic Society.Optimum duration of anticoagulation for deep-vein thrombosis andpulmonary embolism. Lancet 1992;340:873-6.

Search in Medline 1966-present

Keywords:

Anticoagulants, Colonoscopy, Haemorrhage

21 Results in between 1993-2006

9 Papers about Colonoscopy+Polypectomy

Most recent study

High caseload

To investigate the risk of post-polypectomy bleeding in patients taking anticoagulant and antiplatelet agents.

Retrospective Audit

Colonoscopies 01/2000 to 12/2001 = 5593

@ Tertiary referral endoscopy center in HK

Polypectomy=1657 patients

Technique=Electrosurgical polypectomy

Immediate haemorrhage =bleeding from polypectomy site of sufficient severity to require endoscopic intervention as judged by the endoscopist.

Delayedhaemorrhage = PR bleedingwithin 30 days of colonoscopic polypectomy of sufficient severity to require hospitalization for further management.

SPSS, version 10.0

Multivariate logistic regression analysis= effect of potential risk factors for bleeding, adjusted for the effects of each of the other potential factors

Potential risk factorsthat were analyzed:

size of polyp

location of polyps

method of polypectomy (snare or hot biopsy)

use of antiplatelet agents (aspirin, ticlopidine, clopidogrel), NSAIDs, or Warfarin

skill of the endoscopist (trainee or instructor)

presence of underlying renal impairment.

Total of 1657 colonoscopic polypectomies

Post-polypectomybleeding =37 cases (2.2%)

(32 immediate, 5 delayed)

Bleeding or no bleeding: no difference ingender, size of the largest polyp, location of polyps

Freq. of bleeding in instructors vs. trainees similar

Patients with underlying renal diseases similar

Patients with bleeding were significantly older !

Immediatepost-polypectomy bleeds

Mild=31

Moderate =1( Hb >4 g/dL)

All 32 patients Tx by endoscopic methods(no need for angiography or surgery)

Haemostasis achieved through:

Epinephrine injection (27),

Thermocoagulation (6),

Haemoclip application (3),

Endoloop placement (1).

5 cases = more than one modality was used

Delayed bleeding =5

Mild= 1

Moderate=2

Severe=2

In 4 bleeding at polypectomy site(Tx was endoscopically)

1 Patient needed 3 colonoscopies and emergency angiography before site of bleeding identified

All 5 patients required PC(up to 13 U)

No patient required surgery and no mortality

Aspirin and/or NSAID

6/37 (16%) bleeding group on antipl.agents

213/1620 (13.21%) in non-bleeding group.

No increase in risk of bleeding associated with Aspirin and/or NSAID (p = 0.62)

Warfarin

4/37 (10.8%) in bleeding group were taking Warfarin,

Only13/1620 (0.8%) in non bleeding group

(p < 0.001).= significantly higher risk for bleeding in patients who received Warfarin before colonoscopy

INR in bleeding group not significantly different from non bleeders

median INR 1.41[range 1.09-1.86] vs. med. INR 1.38[range 1.08-1.84]

(The power was 91.1% to detect differences in bleeding related to the use of Warfarin.)

Retrospective Audit

= Non standardizedpreparation of patients

= Non standardized identification and management of bleeding

= No structured follow-up

Mild haematochezia who did not require re-adm. notrecorded

Patients who presented to private hospital with bleeding missed

INR in both groups subtherapeutic

(median INR 1.41[range 1.09-1.86] vs. med. INR 1.38[range 1.08-1.84]

1. Use of antiplatelet agents and NSAIDs not associated with an increased frequency of postcolonoscopic polypectomy bleeding.

2. Warfarin should be stopped and the INR normalized before performing an elective colonoscopy anticipated with therapeuticmaneuvers.

The findings concur with the current ASGE guidelines on the use of antiplatelet and anticoagulant drugs during endoscopic procedures.

Outlines in

Procedure risks

High (Bleeding risk 1-6%)

Low (Bleeding risk

Bleeding and colonoscopic polypectomy

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