Latest on Colonoscopies While Anticoagulated

[Guest]

This was published yesterday.

Colonoscopic polypectomy in anticoagulated patients.
Friedland S, Sedehi D, Soetikno R.
Division of Gastroenterology, VA Palo Alto and Stanford University, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. [email protected]
World J Gastroenterol. 2009 Apr 28;15(16):1973-6.

AIM: To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation. METHODS: Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically. RESULTS: One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia (blood in the bowel movement) at home and did not seek medical attention. The average polyp size was 5.1 +/- 2.2 mm. CONCLUSION: Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.

 

[njean]

This was published yesterday.

Colonoscopic polypectomy in anticoagulated patients.
Friedland S, Sedehi D, Soetikno R.
Division of Gastroenterology, VA Palo Alto and Stanford University, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. [email protected]
World J Gastroenterol. 2009 Apr 28;15(16):1973-6.

AIM: To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation. METHODS: Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically. RESULTS: One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia (blood in the bowel movement) at home and did not seek medical attention. The average polyp size was 5.1 +/- 2.2 mm. CONCLUSION: Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.

Thank you for this info Al. I made a copy to take to my PCP next time I see him.

Can you believe that the doctors in my town will NOT do a colonoscopy unless the patient has been off coumadin for 4 days prior?!!! That's the reason I haven't had one since 1997!

 

[Guest]

This is exceptionally bad since Albuquerque is the home of David Garcia, the MD who is the president of the Anticoagulation Forum, the professional organization of warfarin managers. He is a professor at UNM so they should contact him through there.

Alex Spyropoulos (Dr. Spy since people in ABQ tend to not do well on Greek names) is also one of the top people in the field of blood clotting. His office is at 5400 Gibson Blvd SE.

 

[geebee]

Did I misread? Isn't coming off coumadin for 36 hours prior to the procedure not fully anticoagulated?

 

[njean]

This is exceptionally bad since Albuquerque is the home of David Garcia, the MD who is the president of the Anticoagulation Forum, the professional organization of warfarin managers. He is a professor at UNM so they should contact him through there.

Alex Spyropoulos (Dr. Spy since people in ABQ tend to not do well on Greek names) is also one of the top people in the field of blood clotting. His office is at 5400 Gibson Blvd SE.

I might end up scheduling an appt with these doctors instead even tho it's a 4 hr drive to Albuq from where I live.

 

[Guest]

Gina,
Technically you are right. However, 36 hours is a lot better than 168 hours (one week).
This is like forgetting your warfarin for one day. Unlikely to cause disaster from either clotting or bleeding.

 

[CThrock]

Go Stanford!!!! That's where I had my OHS.. There great!

 

[CThrock]

Norma there's a dr that Christina had a colonoscopy done with here in Tucson,AZ. Might not be such a long travel and you can stay here at my house if you did. Pm me if interested and I'll give you his name. Christina thought he was great. Look forward to maybe using him myself.

 

[njean]

Did I misread? Isn't coming off coumadin for 36 hours prior to the procedure not fully anticoagulated?

So is this to say Gina that I wouldn't be in too much danger if I went off coumadin for 4 days prior to the procedure?

 

[Marty]

Old habits die hard. In this area I believe the majority of gastroenterologists stop Coumadin at least four days prior to diagnostic endoscopy. I discussed this with a GI guy a few years ago( told him about Warren Mead) and he was unmoved and told me to find another doctor. In my old private practise they are doing more and more virtual colonoscopy. Many of the referrals are for patients who don't wish to stop Coumadin and do Lovenox bridge ,and also many who do not wish to be sedated and/or lose a days work. Go to Washingtonpost.com, Health April 28 for a long article about virtual colonoscopy.

 

[geebee]

So is this to say Gina that I wouldn't be in too much danger if I went off coumadin for 4 days prior to the procedure?

My take is that if you are off coumadin for 36 hours you are not fully anticoagulated and may not even be therapeutically anticoagulated like the study states. Granted it is probably safer than being off for 4 days but I drop pretty fast so 36 hours off coumadin would put me below 2.0 and I don't ever do that intentionally.

 

[njean]

Norma there's a dr that Christina had a colonoscopy done with here in Tucson,AZ. Might not be such a long travel and you can stay here at my house if you did. Pm me if interested and I'll give you his name. Christina thought he was great. Look forward to maybe using him myself.

Thank you my friend.....something to consider. In 1997, when I had my last & ONLY colonoscopy, I went to a dr in El Paso but darn if I can remember whether or not he took me off coumadin prior & I don't even remember his name now! My memory is getting sooooo bad!

 

[njean]

My take is that if you are off coumadin for 36 hours you are not fully anticoagulated and may not even be therapeutically anticoagulated like the study states. Granted it is probably safer than being off for 4 days but I drop pretty fast so 36 hours off coumadin would put me below 2.0 and I don't ever do that intentionally.

Yes, me too! I drop like a rock if I have to stop even for one day!!

 

[csutherland]

That would be great if the specialists here would hear to it. I'm going to copy it as well to take in.

Jerry has been putting off a colonoscopy for about 7 months because the anti-fungal medication he's on for 6 months messes with INR anyway and he just didn't want to further "rock the boat."

I sure like the sound of 36 hrs vs several days, and he's already had his experience with Lovenox before a lung biopsy. We don't like those shots!

 

[Ross]

I would be 1.2 in 36 hours. Guaranteed.

 

[Blanche]

Oh, cripes, here we go again

Oh, cripes, here we go again

Just when I need another colonoscopy and Al does too...up jumps the devil of one or several docs who think they have found the Golden rule..again.

One swallow does not a summer make. The research that has dictated protocol is at odds with this new revelation.

We have a member here who lost his dear father because his INR was too, too low when he had a colonoscopy.

I would need to have more than one "o p i n i o n" before I gave up my anticoagulation for a colonoscopy.

Blanche

 

[Cris N]

2 years ago I saw the dr for my first colonoscopy and hemorroidectomy. We discussed the INR issue - he said he would be comfortable with me at 2.0

That was the plan - but, of course, we threw in the Lovenox just for good measure. So the day of the procedures (a Friday) I was at 2.0ish - no problems at all with the the procedures - including removing 2 small polyps. My difficulty came on Saturday & Sunday when I passed some rather large clots. So, I went to the emergency room and was ultimately admitted - dr. sent his baby partner who was clueless!!!. So I finally get on the phone with the dr who did the procedures - he's figuring to go back into surgery to add a couple of stitches somewhere (jeesh this hurts just thinking about it) but decided to try FFP first. Oh, yeah, did I mention that I thought I was so smart that before the initial surgery I upped my warfarin to get a head start on the INR increase?!!!

By the time they got the FFP going my INR was up past 2.5 (and I had administered Lovenox that morning). FFP dropped it down to about 2.0. Spent the night in the hospital - next day all was fine. No more bleeding, just a giant PITA

But the important part of this was that the bleeding was from the hemorroidectomy NOT the colonoscopy and polypectomy.

 

[Guest]

I just spent 3 days at a meeting of anticoagulation people and have some new stuff to add.

First, don't look to scheduling an appointment with Dr. Spy in Albuquerque. Lovelace has mostly dismanteled (at least as a research institution). Spy moved to Hamilton, Ontario two weeks ago. Hamilton is "the research center" of the anticoagulation world. The last thing they need is another world-class anticoagulation doctor. But professionally it is a great opportunity for Alex, so I am happy for him.

Second, the feeling among top anticoagulation docs is this:
1. More and more GI docs are willing to do colonoscopies while someone is fully anticoagulated.
2. A screening colonoscopy is not an urgent procedure.
3. Find a GI doc who will do it while you are anticoagulated.
4. Coordinate IN ADVANCE with your insurance that they will agree to a second colonoscopy to remove polyps if this is necessary.
5. The majority of colonoscopies do not require polypectomies so mostly you will never need the second one.

 

[catwoman]

Al:

That's good to hear.
Was your meeting the Anticoagulation Forum meeting in San Diego? I had seen notice of the meeting at acforum.org's website.

 

[csutherland]

This is, at best, second hand info, but.... My niece's father-in-law died recently of a stroke; he was about 53. He had had toe surgery earlier (I don't know when) and had gone off coumadin. They're thinking this had something to do with the stroke. I don't know why he was on coumadin.

This is the reason I always argue with the dental surgeon, colonoscopy doctor,etc. My dad died of a stroke, too, (not coumadin related) and it's not nice. I am very fearful of this for Jerry.

Hope I didn't hijack this thread in any way.