- 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
2. COLONOSCOPIC POLYPECTOMY
- 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
3. PROBLEMS
- 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)
4. PROBABILITY OF THROMBOEMBOLIC COMPLICATIONS I
- 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.
5. PROBABILITY OF THROMBOEMBOLIC COMPLICATIONS II
- 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
6. PROBABILITY OF THROMBOEMBOLIC COMPLICATIONS III
- 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.
7. WHAT IS THE RISK OF BLEEDING UNDER ANTICOAGULATION IN
COLONOSCOPIC POLYPECTOMY?
- Search in Medline 1966-present
- Anticoagulants, Colonoscopy, Haemorrhage
- 21 Results in between 1993-2006
- 9 Papers about Colonoscopy+Polypectomy
8. Risk of colonoscopic polypectomy bleeding with anticoagulants
and antiplatelet agents: analysis of 1657 cases Aric J. Hui, MD, et
al.Dept. of Medicine and Therapeutics and Dept. of Surgery, Prince
of Wales Hospital, Shatin, Hong Kong, China. in Gastrointestinal
Endoscopy 2004;59:44-8. 9. WHY THIS PAPER?
10. AIM OF STUDY
- To investigate the risk of post-polypectomy bleeding in
patients taking anticoagulant and antiplatelet agents.
11. METHOD
- Colonoscopies 01/2000 to 12/2001 = 5593
- @ Tertiary referral endoscopy center in HK
- Polypectomy=1657 patients
- Technique=Electrosurgical polypectomy
12. DEFINITION OF BLEEDING
- 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.
13. 12: Cotton P, Williams C. Practical gastrointestinal
endoscopy. 4th ed. Oxford: Alden Press; 1996. p. 168.
(Post-sphincterotomy bleeding grading) 14. Statistical analysis
- 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:
- 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.
15. RESULTS I
- 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 !
16. 17. RESULTS II
- Immediatepost-polypectomy bleeds
- All 32 patients Tx by endoscopic methods(no need for
angiography or surgery)
18. RESULTS III
- Haemostasis achieved through:
- Epinephrine injection (27),
- Haemoclip application (3),
- 5 cases = more than one modality was used
19. RESULTS IV
20. RESULTS V
- 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
21. 22. RESULTS VI
- 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)
23. RESULTS VII
- 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.)
24. Critique
- = 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]
? 25. Main findings
- 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.
26. Recommendations of ASGE American Society for
Gastrointestinal Endoscopy Guideline on the management of
anticoagulation and antiplatelet therapy for endoscopic procedures
Gastrointestinal Endoscopy 2002;55:775-9. 27. Recommendations of
ASGE II
-
- High (Bleeding risk 1-6%)