Colonoscopy

[Jimmyk]

ok,
Not the greatest subject to talk about on a Sunday morning, but it seems like the last few times I've been in the doctors office, I was asked , when was the last time you had a colonoscopy ? My response , never. The office is usually very serious about scheduling me for one, but once the topic of me being on warfarin comes up , their not so serious anymore .
Question, has anyone out there ever had a colonoscopy while taking warfarin ? I'm really curious , because I mentioned to my cardiologist one day, that a colonoscopy was recommended because of a colon cancer history in my family. He told me absolutely not.
A coworker of mine who also has a history of colon cancer in his family. When he went in for a check up, there were quite a few polyps removed. This guy is 15 years younger than me, probably 50 pounds lighter. His doc recommend one at an earlier than usual age, because of strong family history . He. Is not on warfarin. After a 2 day rest he came back to work. Within an hour or 2 , he was being taken away in an ambulance , due to an internal bleeding issue. Now from what he told me, They took out a lot of polyps ,and he didn't have enough time to heal.

 

[pellicle]

I have. I'm unclear if your cardiologist is against a colonoscopy. If they are then they are a bit reckless if you ask me. Here is my experience. I see no problems with bridging if that would make you more comfortable with INR management
http://cjeastwd.blogspot.com/2017/12...nt-of-inr.html

 

[Jimmyk]

It seems like the doctors I visit are very cautious to do anything, if you have a life threatening situation, they won’t let you die. When it comes to a preventative procedure, that’s another story.

 

[pellicle]

It seems like the doctors I visit are very cautious to do anything, if you have a life threatening situation, they won’t let you die. When it comes to a preventative procedure, that’s another story.

I expect its all a combination of "uncertainty" and "risk analysis"

they are uncertain to the influence of your AC therapy on the process, the increase in risk of bleed and the risk of clots (caused when you are not on anti-coagulation therapy). This version of the link will print better on a printer:
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html?m=1

Print too the journal article I referenced:
https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation

Together they will help you formulate a strategy and make a call as to "how important is it to have the colonoscopy?"

As I said in my blog article (and you mentioned in your first post) improperly done a colonoscopy can be a significant issue resulting in bleeds from improperly removed polyps. Properly managed its a relatively simple procedure (which is why its usually not done exclusively by experienced operators).

Myself I'd be taking this opportunity to do some readings (say every 2nd day) or your INR and see exactly what happens to your INR. Alternatively Cease warfarin for a week prior to your procedure, and commence heparin daily injections till the day before the procedure. Do not re-commence warfarin or heparin for 2 days after the colonoscopy and take careful note of your stools to look for blood (like someone tipped a glass of bright red cordial into the bowl with your turds). If there are any signs of bleeding REPORT THIS TO THE DOCTOR IMMEDIATELY. Warfarin or no warfarin ... the friend of mine in my blog post did not do that and as I wrote in there HE WAS NOT ON WARFARIN.

Read my article carefully and take that printed to your Dr and make your decisions. Decide in concert with your Dr what you want to do, then advocate for yourself firmly and clearly.

 

[DachsieMom]

This is a great topic. I am 45 and have not had a colonoscopy yet. I asked my cardio, and he said I should be off warfarin for 5 days without bridgingwhenever I have a colonoscopy, as an artificial valve in the aortic position is low risk - but being off warfarin terrifies me. My primary care physician strongly recommended that I bridge, which requires staying in the hospital for 5 days. I have also heard about the virtual colonoscopy, which appears to be covered by insurance if you are on warfarin (but I still have a $5k deductible). I am concerned about radiation exposure with the virtual colonoscopy, as I have already had several ct scans and expect to have more. I am not yet 50, but my mother has had several polyps removed and part of her colon, due to a flat polyp (non cancerous). I am totally confused - hoping technology advances before I need one! What have others done? I am leaning towards virtual colonoscopy, although they are not as accurate.

 

[pellicle]

Hi

That's one of the great things here, person X asks a question and three others benefit from the discussions

... I asked my cardio, and he said I should be off warfarin for 5 days without bridgingwhenever I have a colonoscopy

Not too different to what I did. Did you read my blog post?

as an artificial valve in the aortic position is low risk - but being off warfarin terrifies me

It shouldn't... It's a calculation. Texting while driving should terrify you ...

My primary care physician strongly recommended that I bridge, which requires staying in the hospital for 5 days.

Which of the two do you think should have greater knowledge of heart related issues?

Bridging is simply injecting yourself with a single use ampule of a different anticoagulant. Heparin. It no more needs hospital than taking warfarin or a diabetic doing their daily insulin injections.

Based on what you've said, I'd find a better physician...

 

[jwinter]

I have had 2 colonoscopies in the last year. Both were done by the gastrontologist. I would really check into that as I would not have let just anybody do it.

Both times the gastrontologist had me go to my primary care provider for bridging instructions. Went off Warfarin five days before procedure and started bridging with Lovenox shots twice a day. Following procedure the first time I just started back on warfarin the evening of procedure and all worked well.

For my second one, I started bridging and quit taking Warfarin five days before test. I had some bleeding issues (bleeding ulcer in stomach) so I started Warfarin the same evening but continued bridging until my INR was therapeutic.

I would NEVER not have a colonoscopy done because I have an artificial valve and take Warfarin. Colon cancer is nothing to mess with. I have no history in my family but that does not mean I won't be the first.

I was more concerned about the bridging process as both nurses that showed me what to do said they had never given themselves a shot and cannot imagine doing it. I could never be a nurse or in the medical field but that little needle and shot went really well after the first one as I was a bit nervous. Now if I have to bridge and know I won't be home I grab that syringe and alcohol prep, throw them in my purse, and just take care of it when needed.

Had my OHS just about two years ago and have bridged about 4 or 5 times without a problem. Preventable or early detection of cancer is very important. Find the right specialist and have it done. Oh and bridging in the hospital? No need as far as I know,

 

[MartinF]

I've had 2 colonoscopys. No issues. Dr knew and gave me instructions on warfarin. I have a tissue valve and my INR is not as critical. I've also had a couple minor surgeries that required going off warfarin. No problems but you should work with all doctors on what to do, both on gastro and cardiologist.

 

[pellicle]

Hi

I've had 2 colonoscopys. No issues. Dr knew and gave me instructions on warfarin. I have a tissue valve and my INR is not as critical.

if you don't mind me asking, if you have a tissue prosthesis why are you on warfarin? A-Fib?

Anyway, aside from that I just wanted to say generally sepaking that while Warfarin and Heparin act on different chemical pathways both do the same job: inhibit the capacity for the blood to clot.

The differences is that warfarin takes time to "ramp up" as well as "ramp down", plus you need to make adjustments to its dosage to make sure you are not too unable to clot or too "normal" in clotting. This is the purpose of INR measurements.

Warfarin in that way is more suited to long term AC therapy, and heparin is a firehose that can be turned on and off fast.

Bleeding complications post surgery are problematic and any anticoagulant will cause them. This is where Heparin has its benefit particularly if you are a high risk patient in terms of strokes. You can re-establish a therapeutic protection quickly after wounds have had sufficient time to clot and tissue generation has started. With Warfarin that would take a few more days.

Given that there are many cases of people going off AC therapy for extended durations with modern bi-leaflet valves I don't see there has been a proper response to this changed knowledge. Thus (as I cited in that article) there is a modern view that perhaps we are being too agressive with AC therapy at the risk of causing more bleeds.

I recommend reading that article in the Australian Prescriber.

And I fully agree with jwinter that concerns about management of our AC therapy should not be a reason to avoid procedures aimed at preventing cancers. Cos if you don't get those polyps removed you may just be in bigger trouble.
​​​​​​​

 

[epstns]

Since we're discussing colonoscopies, let me ask a related question. What, if any, antibiotic prophylaxis have your doctors recommended for your procedures?

The reason I ask is that I, at the ripe old age of 70, have NEVER had a colonoscopy. My original cardio said that prior to valve surgery, if I wanted a colonoscopy, they would need to administer significant IV antibiotics before, during and after the procedure. To do this, they would have to admit me to the hospital, and absent any symptom or condition warranting an immediate colonoscopy, insurance wouldn't cover the hospital stay. I never pushed it. . .

Since that time, I have been treated for prostate cancer (external beam radiation) and have periodic hem-occult tests to ensure that there is no blood in my stools, as that would be a sign of significant after-effects from the radiation - or colon issues. All have been clear, so nobody is pressing me for the colonoscopy right now.

 

[MartinF]

My colonoscopys were done at a surgical center, not a hospital. They gave the antibiotics in the IV. Make sure they know that you need that in your pre-procedure meeting and when they are preping you.

 

[pellicle]

Hi Steve

Since we're discussing colonoscopies, let me ask a related question. What, if any, antibiotic prophylaxis have your doctors recommended for your procedures?

none (but as I'm on a daily 1500mg I often forget to consider it ;-)

There is a bowel prep done before which evacuates you like you wouldn't believe ... many observe this is far more uncomfortable than the procedure. I would not disagree.

This is done 12 hours before the procedure and you're nil by mouth till after it. This is to ensure that your bowel is essentially just as squeeky clean as it can be (I have pictures to demonstrate this if you wish to see).

The reason I ask is that I, at the ripe old age of 70, have NEVER had a colonoscopy.

I'd say that its pretty clear that having reached that age you are not really in need of one. I only had mine because they identified some "promininces" in my PET scan (in search of my chest bacteria {which wasn't clarified}) and I was advised to get these checked out because my PET scan is normally used for identifying cancers.

My original cardio said that prior to valve surgery, if I wanted a colonoscopy, they would need to administer significant IV antibiotics before, during and after the procedure.

interesting, and perhaps over-the-top .. but perhaps he has reasons I'm unaware of

Down that far in the bowel there are not likely to be any serious pathogens present (or you'd have bowl flora problems already showing themselves) and so I'd expect that simply oral prophalaxis would be ample (maybe even mildy excessive). But that's just my first thoughts.

 

[jwinter]

No antibiotics with either of mine.

 

[tom in MO]

Five years ago I was told by my colorectal surgeon that a colonoscopy with a mechanical valve does not require you to go off warfarin or bridge. However, if you want them to remove polyps or take biopsies you need to go off warfarin. You can do the colonoscopy w/o those activities, the risk is that if they find things that need biopsy or removal, you have to have a second colonoscopy for that work. God help you if the doctor gets paid more for the number of biopsies or polyps removed From my reading at the time, I gathered that the recommendations have changed over time. About 2 years ago in one of the anti-coagulation summaries I also read that colonoscopy w/o biopsy or polyp removal could be done w/o stopping anti-coagulation therapy. I can't remember the reference though.

I believe whether or not you need to bridge for something depends upon the type of valve and position. My cardio says my St. Jude at 2-2.5 INR can easily handle no warfarin w/o bridging for a few days, which I did last year for a procedure that involved some internal bleeding and scabbing. My only problem was returning to warfarin and having problems when the scabs would break open during later healing.