Coumadin and colonoscopies

[Mary]

There has been a great deal of discussion about undergoing a colonoscopy while on coumadin. I'd like to share my father- in- law's recent experience.

Jerry hasn't had a valve replacement, but he has had surgery for an abdominal aortic aneurism besides having two pacemakers, an ablation procedure and dealing with CHF. He's been on Coumadin for a long time.
He underwent a colonoscopy seven days ago-routine-and everything seemed fine, but Saturday he started passing new blood that increased in duration and severity literally with every passing hour. He was rushed to the ER, and air evacuated out yesterday to a larger facility. He was placed in ICU, was given three pints of blood plus platelets to maintain his iron as they attempted to control the blood loss before performing another colonoscopy. Of course, the coumadin had been stopped by this time.
He underwent the procedure, again, this morning, and they found the nick that had been made during the initial procedure. It was cauterized, and it seems to be holding.
We assume this story will have a happy ending, but we were afraid he would die before they could find the source of the bleeding. I hope his experience serves as a reminder that all invasive procedures carry some risk, and we should maintain a healthy respect for the dangers involved.

 

[Rich]

Hi Mary,
Well first off I hope he is OK and they have the problem resolved
All these procedures can be a real pain while on Coumadin.
Iv'e been on it for almost nine years and I fully understand the problems.
I went through that procedure several months ago.
My cardiologist had me stop it for two days prior, they removed five polyps.
Fortunately they were all benign and I had no bleeding afterwards.
A lot of us have read the stories of what could, and has happened to people when stopping Coumadin.
It is scary stuff.
Personally I have stopped Coumadin on at least five different occasions for one thing or another.
My cardiologist is vice-chief of cardiology for the best heart hospital in Michigan. He claims the chance of something going wrong is about 2-3%.
It still scares me but those are pretty good odds.
Rich

 

[Marty]

The diagnostic part of colonoscopy is usually benign. The therapeutic part often not.I had a patient last week who had a 3 mm. polyp removed but perforated.
Free air all through his abdomen ( quite a sight on just plain X-rays). Called the urgent care doctor who dialed 911 and shipped him to hospital.

 

[Guest]

Mary,
It is awful when these things happen, sorry to hear about this. However, please consider this. He will probably be fully recovered much sooner than if he had stopped warfarin and had a stroke. Bleeding is serious and can be an emergency as you described but you hardly ever hear of a bleeding episode that causes the person to be paralyzed, unable to speak, unable to feed themselves or unable to get to the toilet. Blood is fairly easily replaced, but the brain...

Marty,
Your case didn't have anything to do with warfarin, did it? These things just happen, don't they?

 

[Marty]

No, Al, Coumadin not involved. Patient was a healthy 70 yr old man having a routine procedure. His 3mm hyperplastic polyp at the hepatic flexure was benign. After the perforation he had right hemicolectomy and ileostomy. I relate this sad story to emphasize that some of these "routine" diagnostic procedures have risks both for those on and off Coumadin.If this happened to a Coumadin patient it would be a horrific problem because he would probably need to be off both Coumadin and Lovenox until the risk of bleeding from the colectomy subsided.
Ask one of your surgeons how they would handle this complication if it occurred in a Coumadin patient on hold or bridged with Lovenox. I'm curious.

 

[MarkU]

I'm having a colonoscopy next week. Their nurse insisted that I go off Coumadin for three days prior. I replied that I wouldn't agree to anything until they had cleared it with my cardiologist. She got real huffy with me but I stood my ground.
So today I get an urgent call from my cardiologist's office telling me under no circumstances to go off my Coumadin cold turkey. They want to check my INR, put me on Lovenox bridge therapy and then get my INR tested again following the colonoscopy. I feel fortunate that my cardiologist is looking out for my best interests - I get tired of the hassles from dentists, and others who want to make their lives easier without concern of the greater consequences to my health.

Mark

 

[Mary]

Update to the original post: Jerry will be released Thursday but as of tonight has had 8 units of blood plus platlets.
That's a lot of blood!

 

[Guest]

Most of the surgeons would be very happy if they could turn the blood to strawberry Jell-O a week before the surgery and have it remain semi-solid until a week post-op. I know that didn't answer your question, Marty, just an observation.

 

[MarkU]

Just got back from my appointment at my anti-coag lab to get my INR checked (3.5) and review my Lovenox bridge therapy for my colonoscopy a week from Friday:
- I stop my Coumadin on Sunday night.
- Tuesday I start my Lovenox injections, two a day, twelve hours apart.
- Last Lovenox injection at 8 PM Thursday.
- Colonoscopy Friday morning, sometime between 8AM and noon (they told
me to call Thursday afternoon for an exact time to show up...)
- One last Lovenox & start my Coumadin again on Friday afternoon/evening.
- Back to the lab to get my INR checked again at 8AM Monday morning.

Like I mentioned earlier, I feel confident that my anti-coagulation lab is looking out for my best interest. More so than the gastro nurse who just flat told me to go off Coumadin for three days and didn't want to listen to my concerns or objections.

Mark

 

[Guest]

Better than going off all the way. But you should have Lovenox for a few days until your INR gets back up. It will still be low on Monday morning, because it takes about three days for the first dose to show back up. I don't check the INR until the people have been back on it for a week. Monday's will just prove what you already knew -- that you missed a few doses.

 

[tommy]

Mark,

I really don't think that your INR will drop from 3.5 to out of range (low) missing only 2 doses. Likewise, your INR will not be close to range with only 2 doses after the procedure. There is some guess work going on here when verification is available. This guess work will likely cause you to take Lovenox more than is necessary.

My bridge process (twice) was to get the INR below 2.0 before starting Lovenox, and later get it back up to 2.0 before stopping Lovenox. The date to stop Coumadin was a guess, but everything after that was planned based on the INR. You might approach your doctors about this approach.

My concern with bridge therapy is the period of time when taking both Lovenox and Coumadin. After minor surgery (inguinal hernia), this double "coverage" caused some drainage internally and at the incision. So, I chatted with the GI doc before the colonoscopy to encourge him to take his time and be sure to cauterize real well anything that he snipped. I had no problems following the colonoscopy, including several small benign polyps.

I tested my INR several extra times to reduce the period of double "coverage". I'd rather take a few extra INR tests than take a few extra Lovenox shots.

Home-testing make this very conveinient, but it can be done with a lab. Same-day results would be very helpful.

PS...you may have to check with several pharmacies to find one that will split a box (10 in a box). The stuff is expen$$$$ive!. Al previously suggested a pharmacy at a hospital. I've also found Target to be very flexible.

Good luck with the tunnel rat.

 

[warrenr]

Colonoscopy/Coumadin

Colonoscopy/Coumadin

Just got back from my appointment at my anti-coag lab to get my INR checked (3.5) and review my Lovenox bridge therapy for my colonoscopy a week from Friday:
- I stop my Coumadin on Sunday night.
- Tuesday I start my Lovenox injections, two a day, twelve hours apart.
- Last Lovenox injection at 8 PM Thursday.
- Colonoscopy Friday morning, sometime between 8AM and noon (they told
me to call Thursday afternoon for an exact time to show up...)
- One last Lovenox & start my Coumadin again on Friday afternoon/evening.
- Back to the lab to get my INR checked again at 8AM Monday morning.

Like I mentioned earlier, I feel confident that my anti-coagulation lab is looking out for my best interest. More so than the gastro nurse who just flat told me to go off Coumadin for three days and didn't want to listen to my concerns or objections.

Mark

Mark,
Why are they having you stop coumadin to begin with?

 

[MarkU]

Mark,
Why are they having you stop coumadin to begin with?

In case there is any bleeding during the procedure due to taking biopsy samples, removing polyps, or if the doc makes a wrong turn and nicks something.

If it was strictly up to me I'd just stay on my Coumadin and take my chances with the bleeding. I've never been a bleeder since I've been on Coumadin. My sense is the whole thing is driven by the GI doc's malpractice insurance company.

I failed to mention previously that I do continue the Lovenox for three days after the procedure, along with resuming my Coumadin.


Mark

 

[tommy]

The way I read the guidelines (link below), the AVR is a "low risk condition", and snipping polyps is a "high risk procedure". That means that going off Coumadin is called for. Considering heparin therapy (we use Lovenox instead) is not even called for in this situation, but many cardios (mine included) insist on it. This was my experience.

http://www.asge.org/nspages/practice/patientcare/anticoagulation.cfm#PageLink05

The choice is that you can do a diagnostic colonoscopy while still on Coumadin. That is considered a "low risk procedure" even with biopsy. If they find polyps to snip, then you come back a second time as a "hish risk procedure" and use the Lovenox bridge. If they find no polyps to snip, you are done.

BTW, MVR replacement is considered "high risk condition" where AVR is considered "low risk condition" unless you had "prior thromboembolic event" before.

I opted to do the one-shot deal with Lovenox bridge, and they did ship 4 small polyps - all benign. My opinion is that if you know that you have thromboembolic issues, the diagnostic colonoscopy sounds like a good idea.

Good luck, Mark.