Colonoscopy Scheduled

[tommy]

My fifty-year colonscopy is next Tuesday. It will be my first.

I've been over and over the concepts of virtual colonscopies, staying on Coumadin, Lovenox bridges, and heparin. Regardless of what I do, there is risk. It's a shame that there must be risk for a diagnostic procedure. "Virtuals" are just not good enough (yet?).

I'm least uncomfortable (double negative intended) with the conventional procedure using a Lovenox bridge. I've done Lovenox bridges twice before. I don't like them, but like the alternatives less.

The whole idea of poking around and possibly bleeding where the sun doesn't shine gives me the willies.

 

[Ross]

My wife and I talked about this today. My Doctor has suggested it to me and after watching my mom battle her cancer and numerous surgeries "down there", I'm not sure I even want to start on that path.

 

[bvdr]

I think the worst part of the colonoscopy is the prep. However, the next time I have to have one I will ask them to give me more medication than they did. I did have some pain that I felt was unnecessary during the procedure.

When I have my next one I think I'll ask for the Lovenox again. I don't want to be in the hospital if I can avoid it!

 

[tommy]

Doctors have talked.

Doctors have talked.

My Coumadin clinic nurse just called with my instructions. They have changed a bit from my last Lovenox regimen. This program uses a little less Lovenox.

Hold 4 doses (days) of Coumadin prior to the procedure.
Begin Lovenox when the INR is below 2.0 (was 2.5).
Take my last Lovenox 24 hours prior (was 12).

After the procedure, the instructions may vary depending on the size of any slices. The GI doc will give me orders at discharge.
For small slices (or no slices ), I can expect to start Coumadin and Lovenox 12 hours after.
For larger slices, start both 24 hours after (this wouuld be a change).
Stop Lovenox when my INR reaches 2.0 (was 2.5).

The changes mean that I have a smaller window to use Lovenox. That measn fewer dose fo the stuff . I like that.

The other change means that I will be unprotected for at least 24 hours (maybe 36) instead of 12. My trusted cardio ordered it that way. Any thoughts?

They will cauterize any slices. That sounds like fun.

I have some Lovenox left over from September. The expiration date is far from expired, but I have lost 20 lbs. so the dose is too high . I will waste a small portion of each syringe so I can use what I have and get the correct dose.

 

[bvdr]

In my mind, it seems that coumadin should be restarted even the morning of the procedure since it doesn't begin to affect your anti-coagulation for a couple of days. Did you check Al's website for the procedure listed there? It seems that it was different than what you are being directed to do.

Whichever way you go, I wish you the very best results and hope you get a very good report. Let us know when you find out!

 

[Guest]

The main thing is that you have greatly reduced your time below range from being off of it for up to a week.

When you waste some of the Lovenox you can expect a lot more bruising. The Lovenox on the outside of the needle will stop blood from clotting around the injection site. If you try to wipe the Lovenox off, you will remove the silicone coating on the needle and it will feel like a harpoon going in. I don't mean that you shouldn't do it, just letting you know what to expect.

 

[tommy]

Al,
That explains why sometime in the past I bruised and sometimes not. It was my technique in clearing the air off the top of the syringe. So I guess I should be as "clean" as possible as I shoot the 10% into the sink. I'll be sure to get the right dose after these are used up.

I'd rather have belly bruises than colon bleeders . I'd rather have colon bleeders than a stroke . Just get this thing over with.

Good point about the total window. On the old regimen, I used 14 doses of Lovenox for a bridge (6 left over). Let's see how many I use this time. Also, my Coumadin Clinic nurse has already pre-spotted pharamacies that stock Lovenox and will break boxes so I don't have to buy 10 doses at a time . I won't have to buy over-buy the stuff this time. I'm predicting 10 doses of Lovenox.

Betty,
Good point about possibly starting Coumadin right away! I'll mention it during my discharge conversation. The doc will be in a better postion to be flexible after the procedure. I'm sure they don't want to commit to anticoagulants until they are sure that I won't bleed (excessively). But once I start back on Coumadin, I don't see why they won't have me double up (say the second coumadin dose). Another conversation for discharge orders.

Thanks again.

 

[Guest]

Because of the lag time before warfarin starts working, there is no reason to wait beyond the evening of the procedure to restart warfarin.

 

[tommy]

Al,
Right. If they are that concerned about delaying restarting the Coumadin, I would expect it to be due to some specific serious issue that would likely need to be addressed one day at a time (let's not go there).

Thanks.

 

[csutherland]

Jerry had a colonoscopy done a few months ago. I was scared about his stopping the warfarin; then on top of that, they took off one polyp so gave instructions for him to wait another few days before restarting the warfarin. I argued with the Dr a little, letting him know that we were more concerned with a stroke than any possible rectal bleeding. He said to go ahead and start back earlier than he had said. I don't remember the exact time; I do know that he had absolutely no problem with either bleeding or INR.

 

[corky]

Lovenox Air Bubble, Check this site

Lovenox Air Bubble, Check this site

http://www.aventis-us.com/PIs/lovenox_TXT.html#Dosage and Administration

If this doesn't sent you to a site for instructions about administration, let me re-cap. The bubble should be left in so as to help prevent any leaking and also to help prevent bruising,..................good luck
Corky

P.S. how about administration of Antibiotics prior to colonscopy. I was told to premedicate before colonscopy

 

[tommy]

Celia,
Right. I would rather bleed than stroke. I will be loathe to stay off anticoagulants very long. I prefer Coumadin to Lovenox and don't see why I wouldn't start Coumadin immediately after the procedure.

Corky,
Thanks. I'm going to use up the 6 doses that I already have and will waste 10% to take my dose down for the 10% weight loss. So I will lose the bubble on those doses. I called the doc today and left a message about antibiotocs. Tomorrow I'll get the answer. It is not a sterile procedure.

 

[Mary]

Tom and others,
My cardiologist said to make sure I was put on antibiotics before a colonoscopy. He said it would also be needed if I ever underwent any type of invasive bladder procedure.
Mary

 

[catwoman]

Tom:

Good luck next Tuesday. I had one 3 years ago, 2 very small polyps found. So, my PCP and the GI doc want me to have one this year. If none are found this year, I might not have to have one again for 5 years.

I didn't have a problem with the prep. There was very very little discomfort with the procedure. Whole thing went so well I wondered why so many people complain about having a colonoscopy (not talking about Coumadin patients, obviously!).

 

[tommy]

Duhhhhhhhhhh!

Duhhhhhhhhhh!

I went round and round today with the GI and cardio's office. Each nurse said that the other needed to write the prescription for antibiotic. Then finally after speed dialing for 15 minutes late this afternoon, I was told that I'll get antibiotics IV before and during the procedure. Duhhhhhhhh, clear liquids only!

Have a great weekend.

 

[sharon]

colonoscopy

colonoscopy

I spoke to the doc that will do my colonoscopy - if I let him - and he said that he would not take me off the coumadin for the test. If anything was found that needed to be removed I would have to go off the coumadin at that point and go thru the "internal cleansing" again. I'm hoping that nothing will show up! I know that the preparation for the procedure is worse than the colonoscopy itself but being off coumadin sure does scare the heck out of me.
Sharon

 

[tommy]

"Dirty" deed is done

"Dirty" deed is done

Procedure went real well. The doc snipped 4-5 polyps. I went in at 6AM was home by 10AM. I'm still a little sluggish from the "vapors". Otherwise fine, and relieved.

Staff was wonderful. Got antibiotics IV starting prior to procedure. Spoke to both the GI doc and "vapors" doc just before lala land. I went under with great confidence. 100....99...98.....zzzzzzzzzzz.

So far only 3 doses of Lovenox. Will restart Coumadin and Lovenox tonight. Haven't tested the "system" to see if there is any bleeding down there. The doc said there may be some but not much. I'll stay on soft foods another day just to give those little snippits some slack. After a day of liquid diet, soft foods will be a treat.

Prep was unpleasant but not terrible. The worst part is that I just felt blahhhhhhhhhh for an evening.

Pathology results in a week. Follow up appt in 2 weeks. Expecting all to be normal.

Normal activity tomorrow. Based on my previous experiences with Lovenox, I'll define "normal" as light walking for a day or two. No running for a few more days - until I reach the other side of the "bridge" - my choice.

Maybe I'm over cautious for staying on soft foods and easing back into running, but I want this to be a one-way street. So far, so good.

Time for another nap...................

 

[catwoman]

Tom:
Sounds like everything's on track.
I had 2 polyps removed 3 years ago. Was a piece of cake. Had regular food that same day...
(Don't know how this message will come across ... have a "new" (previously owned) laptop I've just gotten and have set it up w/ internet.)

 

[warrenr]

perioperative anticoagulation management

perioperative anticoagulation management

Not only does the ASGE Standard of Practice Commitee say coumadin should not be stopped for colonoscopy in heart valve patients so does this Med Alert
http://www.bestpracticeofmedicine.com/index.asp?page=alertsarchive&news_id=5096&alert=MD

P.S. for those of you that remember what happened to my father in march, he is still in Whetsone Care Facility, Columbus, Oh. If I were in all of your shoes (being on coumadin) I would gladly take the small risk of a little bleeding vs the risk of having a massive stroke like my father and having to endure the aftermath of the stroke

thanks
warren r mead

 

[tommy]

Warren,

I am truly sorry about your father. I appreciate your elevating this issue for the rest of us. Here's the way I see the ASGE and MDAlert Guildelines:

1. For diagnostic colonoscopy (including biopsy), but without removing polyp(s), no change in anticoagulation is recommended. This may be new information and lifesaving for some, but requires a 2-step process if anything is found. Then you still have to deal with one of the processes below.

2. If a poly needs to be removed, stopping warafarin/coumadin for 3-5 days is recommemded. a) For a mechanical aortic valve, that is all that is recommended. I disagree with this approach. b) For a mitral valve or previous history of clotting, heparin therapy is recommended. This is what I did.

I could have chosen to have a diagnostic colonoscopy (#1), with the chance of a repeat procedure to remove any polyps that were found. Instead I decided to do it all in one step. That turned out to be a correct approach as 4 polys were removed. Was I stupid? Was I lucky? It was my decision. My Lovenox bridge was actually a step beyond the recommendations.

For those with a previous clot/stroke history, starting with a diagnositc colonoscopy (staying on warfarin) would be a good idea in my opinion. If nothing is found, then you are done with less risk.

Frankly the Lovenox bridge is a royal inconvenience because I bleed more on Lovenox than I do on Coumadin. I'll be another couple of weeks gettting my INR straightened out. I hope that the virtual colonoscopy technology is sufficient next time.