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Ling X, Lin R, Chen Y, Nie C, Sheng L, Liu J, Han C, Ding Z. The risk of aspirin induced postoperative hemorrhage: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:981-992. [PMID: 36245097 DOI: 10.1080/17474124.2022.2137489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE Current guidelines recommend aspirin maintenance for high-risk endoscopic procedures. Some Asian physicians noticed increasing postoperative bleeding in patients taking aspirin. We aimed to explore whether risk of postoperative hemorrhage due to aspirin differs in the East and the West. METHODS PubMed, EMBASE and Cochrane library database were systematically reviewed. We only included trials that met our criteria. RESULTS There is significant association between aspirin and postoperative bleeding (P < 0.001), especially in Eastern population (data from Japan, Korea, Turkey and China, P < 0.001). Result from the West (data from America, Canada and Australia) had no statistical significance (P = 0.07). For Easterners, aspirin increased bleeding risk after endoscopic submucosal dissection (ESD) and endoscopic sphincterotomy (EST). For Westerners, aspirin increased bleeding risk post endoscopic mucosal resection (EMR). For patients undergoing ESD, those who continued to receive aspirin had higher bleeding risk than patients who interrupted it for more than 7 days (P = 0.005). CONCLUSION Aspirin increases risk of postoperative hemorrhage. Easterners are more likely to suffer from bleeding after aspirin administration than Westerners. Stopping aspirin for more than 7 days may be advisable to control bleeding post ESD for patients with low risk of thrombosis.
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Affiliation(s)
- Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yanhong Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chi Nie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liping Sheng
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Ellison PL, Holman N, Wallace K, Cote GA, Elmunzer BJ, Brock AS. Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy. Endosc Int Open 2020; 8:E708-E716. [PMID: 32490153 PMCID: PMC7247888 DOI: 10.1055/a-1134-4813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/14/2019] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration. Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence. Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction ( P = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk. Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.
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Affiliation(s)
- Parker L. Ellison
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Nathan Holman
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Kristin Wallace
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Gregory A. Cote
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B. Joseph Elmunzer
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Andrew S. Brock
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
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Study design of endoscopic polypectomy on clopidogrel (EPOC): A randomised controlled trial. Contemp Clin Trials Commun 2019; 16:100479. [PMID: 31737799 PMCID: PMC6849125 DOI: 10.1016/j.conctc.2019.100479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023] Open
Abstract
Concurrent cardiovascular disease and antiplatelet use (clopidogrel, prasugrel and ticagrelor) use poses a significant peri-endoscopic management challenge with a paucity of high-quality evidence available. Antiplatelet temporary interruption places patients at risk of serious cardiovascular thrombotic events. Continuing these agents potentially increases the risk of procedure related bleeding however this risk could be sufficiently mitigated by cold snare polypectomy and endoscopic clipping to manage intraprocedural bleeding, making routine colonoscopy on continued antiplatelet agents safe. The EPOC trial will examine whether continuation of antiplatelet therapy (clopidogrel, prasugrel or ticagrelor) as single or dual therapy with aspirin, is inferior or superior to temporary interruption of antiplatelet therapy, current standard of care, with regard to the use of endoscopic rescue clips or clinically significant post-polypectomy bleeding after cold snare polypectomy of polyps ≤10 mm. EPOC is a parallel group, proceduralist-blinded randomized controlled trial comparing recruiting patients on antiplatelet therapy undergoing elective colonoscopy. This trial is underway throughout Australia and New Zealand with a view to expanding to additional sites. 496 subjects in each arm are required for this study. EPOC is the first randomised controlled trial comparing temporary interruption with continuation of antiplatelet therapy in patients undergoing elective colonoscopy.
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Yao C, Chiu Y, Wu K, Tai W, Hu M, Chou Y, Liang C, Lu L, Chuah S. The effect of discontinuation of aspirin on colonoscopic postpolypectomy bleeding. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Chih‐Chien Yao
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Keng‐Liang Wu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
- Graduate Institute of Clinical Medical SciencesChang Gung University Taoyuan Taiwan
| | - Wei‐Chen Tai
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Ming‐Luen Hu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Yeh‐Pin Chou
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
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Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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Lee MG, Kim J, Lee SH, Lee BS, Lee SJ, Lee YS, Cha BH, Hwang JH, Ryu JK, Kim YT. Effect of sustained use of platelet aggregation inhibitors on post-endoscopic sphincterotomy bleeding. Dig Endosc 2014; 26:737-44. [PMID: 24673356 DOI: 10.1111/den.12271] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/10/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The effect of platelet aggregation inhibitors (PAI) on post-endoscopic sphincterotomy (ES) bleeding in patients who cannot discontinue PAI for sufficient time in urgent conditions has not been identified. The present study analyzed the effect of sustained use of PAI on post-procedural bleeding in patients undergoing ES. METHODS A total of 762 patients were grouped into one of the following groups: no-PAI group (n = 601), continuation group (n = 132), and withdrawal group (n = 29). The continuation group included sustained PAI therapy (sustained user, n = 49) or those in whom therapy was interrupted <7 days prior to ES (non-sustained user, n = 83). The primary outcome was defined as the incidence, type, and severity of post-ES bleeding among groups. RESULTS There were no significant differences between incidence, type, or severity of post-ES bleeding in the three groups. Among 132 patients with continued use of PAI, there was no significant difference regarding incidence and severity of bleeding according to sustained or non-sustained use (P = 0.071 and P = 0.086, respectively). However, post-ES delayed bleeding was more frequent in sustained PAI users than in non-sustained users (7/49, 14.3% vs 2/83, 2.4%) and was significantly associated with sustained PAI therapy in the continuation group (P = 0.013). CONCLUSION Sustained use of PAI without interruption until ES might increase the risk of delayed bleeding.
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Affiliation(s)
- Min Geun Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Internal Medicine, Hanmaeum Hospital, Jeju-si, Korea
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Pan A, Schlup M, Lubcke R, Chou A, Schultz M. The role of aspirin in post-polypectomy bleeding--a retrospective survey. BMC Gastroenterol 2012; 12:138. [PMID: 23046845 PMCID: PMC3527285 DOI: 10.1186/1471-230x-12-138] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 10/04/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Bleeding following colonoscopic polypectomy is a common complication and has been reported to occur in up to 6.1% of patients. Several risk factors have been discussed but their overall contribution to post-polypectomy bleeding remains controversial. The aim of the study was to determine the rate of post polypectomy bleeding and to analyse the role of potential risk factors especially the role of aspirin. METHODS We conducted a retrospective cohort study of all patients who underwent polypectomy at Dunedin Hospital, New Zealand between January 2007 and June 2009. RESULTS During the study period, 514 patients underwent colonoscopy with polypectomy and a total of 1502 polyps were removed. From further analysis we excluded 21 patients; 15 patients had surgery immediately after colonoscopy for the diagnosis of colorectal carcinoma and 6 patients presented with symptoms of an acute lower gastrointestinal bleed prior to colonoscopy. Of the remaining 493 patients, 11 patients (2.2%) presented with post-polypectomy bleeding within 30 days of the investigation of which 8 were on aspirin. In total 145 patients were taking aspirin prior to colonoscopy and 348 patients were not taking aspirin. The use of aspirin was associated with an increased prevalence of post-polypectomy bleeding (OR=6.72, 95% C.I. 1.76 to 25.7). Interestingly, the use of non-steroidal anti-inflammatory drugs (NSAIDs) was not associated with risk of bleeding after polypectomy (OR=2.82, 95% C.I, 0.34 to 23.3). CONCLUSION Our study confirmed a significantly increased risk of lower gastrointestinal bleeding following polypectomy in patients taking aspirin. We would recommend approaching the patient on aspirin coming forward for a colonoscopy with potential polypectomy with caution.
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Affiliation(s)
- Antony Pan
- Gastroenterology Unit, Southern District Health Board, Dunedin, New Zealand
| | - Martin Schlup
- Gastroenterology Unit, Southern District Health Board, Dunedin, New Zealand
- Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ralf Lubcke
- Gastroenterology Unit, Southern District Health Board, Dunedin, New Zealand
| | - Annie Chou
- Gastroenterology Unit, Southern District Health Board, Dunedin, New Zealand
| | - Michael Schultz
- Gastroenterology Unit, Southern District Health Board, Dunedin, New Zealand
- Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Feagins LA, Uddin FS, Davila RE, Harford WV, Spechler SJ. The rate of post-polypectomy bleeding for patients on uninterrupted clopidogrel therapy during elective colonoscopy is acceptably low. Dig Dis Sci 2011; 56:2631-8. [PMID: 21455672 DOI: 10.1007/s10620-011-1682-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 03/11/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND We do not routinely discontinue clopidogrel before colonoscopy because we have judged the cardiovascular risks of that practice to exceed the risks of post-polypectomy bleeding (PPB). AIMS The aim of this study was to compare the rates of PPB for clopidogrel users and non-users. METHODS We performed a retrospective, case-control study of patients who had colonoscopic polypectomy at our VA hospital from July 2008 through December 2009. We compared the frequency of delayed PPB (within 30 days) for patients on uninterrupted clopidogrel therapy with patients not taking clopidogrel. To minimize confounding from differences between groups in conditions that might contribute to PPB, propensity scoring was used to match clopidogrel users with controls based on numerous factors including age, aspirin use, number and size of polyps removed. RESULTS A total of 1,967 patients had polypectomy during the study period; 118 were on clopidogrel and 1,849 were not. Logistic regression analysis revealed no significant difference in frequency of PPB between clopidogrel users and non-users (0.8% vs. 0.3%, P = 0.37, unadjusted OR = 2.63, 95% CI 0.31-22). Matched analyses using propensity scoring also revealed no significant difference in PPB rates between clopidogrel users and non-users (0.9% vs. 0%, P = 0.99). CONCLUSIONS The delayed PPB rate for our patients on clopidogrel was less than 1%, and PPB rates did not differ significantly between users and non-users. Our conclusions are limited by differences in therapeutic methodology between the groups, and our findings are most applicable to small polyps (<1 cm). We speculate that cardiovascular risks of routinely discontinuing clopidogrel before elective colonoscopy may exceed any excess risk of PPB.
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Singh M, Mehta N, Murthy UK, Kaul V, Arif A, Newman N. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010; 71:998-1005. [PMID: 20226452 DOI: 10.1016/j.gie.2009.11.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 11/12/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND The risk of postpolypectomy bleeding (PPB) in patients undergoing colonoscopy on uninterrupted clopidogrel therapy has not been established. OBJECTIVE To assess the PPB rate and outcome and identify risk factors associated with PPB in patients taking clopidogrel. DESIGN Single-center, retrospective study. Demographics, clinical parameters, polyp characteristics, polypectomy techniques, and postpolypectomy events in the groups were compared by univariate analysis. Stepwise logistic regression analyses identified independent risk factors associated with PPB. SETTING Veterans Affairs Medical Center. PATIENTS A total of 142 patients (375 polypectomies) taking clopidogrel (cases) and 1243 patients (3226 polypectomies) not taking clopidogrel (controls). INTERVENTIONS None. MAIN OUTCOME MEASUREMENTS Postpolypectomy bleeding, hospitalization, and mortality. RESULTS The immediate (intraprocedural) bleeding rate was similar in the 2 groups (2.1% vs 2.1%). Delayed (postprocedural) PPB rate was higher in the group taking clopidogrel (3.5% vs 1.0%, P = .02). Delayed bleeding of significance requiring hospitalization and transfusion/intervention was also higher in patients taking clopidogrel (2.1% vs 0.4%, P = .04). The length of hospital stay and interventions for PPB were comparable between the 2 groups. There was no mortality. Concomitant use of clopidogrel and aspirin/other nonsteroidal anti-inflammatory drugs (odds ratio 3.7; 95% CI, 1.6-8.5) and the number of polyps removed (OR 1.3; 95% CI, 1.2-1.4) were the only significant risk factors associated with PPB. Clopidogrel alone was not an independent risk factor for PPB. LIMITATIONS Retrospective study and small number of patients with PPB. CONCLUSIONS The PPB rate is significantly higher in patients undergoing polypectomy while taking clopidogrel and concomitant aspirin/nonsteroidal anti-inflammatory drugs; however, the risk is small and the outcome is favorable. Routine cessation of clopidogrel in patients before colonoscopy/polypectomy is not necessary.
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Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol 2009; 104:3085-97; quiz 3098. [PMID: 19672250 DOI: 10.1038/ajg.2009.469] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.
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Affiliation(s)
- Avelyn Kwok
- Department of Gastroenterology, Concord Hospital, University of Sydney, Sydney, Australia
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Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060-70. [PMID: 19889407 DOI: 10.1016/j.gie.2009.09.040] [Citation(s) in RCA: 339] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 09/29/2009] [Indexed: 02/06/2023]
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Lee SY. Differences in Managing Anticoagulants and Antiplatelets for Gastrointestinal Endoscopy between East and West. Gastroenterology Res 2009; 2:67-80. [PMID: 27956957 PMCID: PMC5139821 DOI: 10.4021/gr2009.04.1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2009] [Indexed: 12/25/2022] Open
Abstract
Decreasing the bleeding risk associated with gastrointestinal (GI) endoscopic procedures and minimizing the thromboembolic risk of withdrawing medications are very important for the patients taking anticoagulants and antiplatelets. Western guidelines on managing anticoagulation and antiplatelet medications in GI endoscopy suggest a polypectomy with aspirin medication or a biopsy with warfarin medication. However, Eastern endoscopists’ adherence to Western guidelines may be responsible for Easteners experiencing massive bleedings. During the cessation of drugs, it should be emphasized that Asians may be predisposed to different forms of embolism more likely to be of the cerebrovascular system, whereas Westerners more likely to be of the cardiovascular variety. To better understand the differences between the East and West, differences in drug metabolism should be considered that results in greater body weight-normalized plasma unbound clearance of drug in Easterners. Taken as a whole, different managements are required for GI endoscopy in patients on anticoagulation and/or antiplatelet medications based on differences in metabolism of drugs, risk of hemorrhage, and forms of thromboembolism.
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Affiliation(s)
- Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, 4-12 Hwayang-dong, Gwangjin-gu, Seoul 143-729, South Korea. E-mail:
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Lee SY, Tang SJ, Rockey DC, Weinstein D, Lara L, Sreenarasimhaiah J, Choi KW. Managing anticoagulation and antiplatelet medications in GI endoscopy: a survey comparing the East and the West. Gastrointest Endosc 2008; 67:1076-81. [PMID: 18384789 DOI: 10.1016/j.gie.2007.11.037] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 11/13/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anticoagulation and antiplatelet medications may potentiate GI bleeding, and their use may lead to an increased need for a GI endoscopy. We hypothesized that there might be different practice patterns among international endoscopists. OBJECTIVE To explore the differences in management practices for patients who receive anticoagulation and antiplatelet medications from Eastern and Western endoscopists. DESIGN International survey study. SETTING Academic medical centers and private clinics. SUBJECTS Members of the American Society for Gastrointestinal Endoscopy (ASGE) in Eastern (Korea, Japan, China, India, Thailand, Singapore, Malaysia, and Philippines) and Western (United States and Canada) countries were invited to complete a Web-site-based questionnaire. In addition, the questionnaire was sent to university hospitals in South Korea and academic institutions in the United States. METHODS A survey was administered that contained detailed questions about the use of an endoscopy in patients on anticoagulation and antiplatelet medications. MAIN OUTCOME MEASUREMENTS Different opinions and clinical practice patterns regarding the use of anticoagulation and antiplatelet medications by Eastern and Western endoscopists. RESULTS A total of 105 Eastern and 106 Western endoscopists completed the survey. Western endoscopists experienced more instances of procedure-related bleeding (P = .003) and thromboembolism after withdrawal of medications (P = .016). Eastern endoscopists restarted medications later (1-3 days) than Western endoscopists after a biopsy (same day) (P < .001). Eastern endoscopists withdrew aspirin for more than 7 days before a polypectomy and then restarted it 1 to 3 days after a polypectomy, whereas Western endoscopists performed a polypectomy without withdrawing aspirin (P < .001). ASGE guidelines were followed less often by Eastern than by Western endoscopists (P < .001). LIMITATIONS Low response rate, heterogeneity of the sample, and recall bias. CONCLUSIONS The opinions and clinical practice patterns for the management of anticoagulation and antiplatelet medications differed significantly between Eastern and Western endoscopists. The lack of uniformity in practice patterns suggests that more data and better education are required in the area of GI endoscopy for patients on anticoagulation and antiplatelet medications, particularly given that individual patient characteristics may be associated with unique types of complications.
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Affiliation(s)
- Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Tamai Y, Komatsu-Ishizawa T, Takami H, Nakajima H, Fukuda S, Munakata A. MANAGEMENT OF ANTIPLATELET THERAPY FOR ENDOSCOPIC PROCEDURES: OPTIMAL CESSATION PERIOD OF ANTIPLATELET THERAPY FOR JAPANESE. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.2007.00751.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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15
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Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17:145-56, viii. [PMID: 17397781 DOI: 10.1016/j.giec.2006.10.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Current polypectomy tools and techniques are inadequate to prevent all postpolypectomy bleeding, perforation, and postpolypectomy syndrome; however, adherence to certain principles can substantially reduce the risk of these complications. This review does not focus on technical aspects of colonoscopy that are directed toward preventing complications of failed eradication. Rather, the authors focus on the classic complications of bleeding, perforation, and their prevention. New technologies that could further reduce or eliminate perforation and bleeding after polypectomy are sorely needed.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 N University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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Kim HS, Kim TI, Kim WH, Kim YH, Kim HJ, Yang SK, Myung SJ, Byeon JS, Lee MS, Chung IK, Jung SA, Jeen YT, Choi JH, Choi KY, Choi H, Han DS, Song JS. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 2006; 101:1333-41. [PMID: 16771958 DOI: 10.1111/j.1572-0241.2006.00638.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aims of this prospective study were to document the incidence of colon immediate postpolypectomy bleeding (IPPB) according to grade, and to identify potential risk factors of IPPB in patients who have received complete colonoscopy and polypectomy because of a colorectal polyp. METHODS This was a prospective, cross-sectional study of 5,152 patients treated at 11 tertiary medical centers between July 2003 and July 2004. Patient-related, polyp-related, and procedure-related variables were evaluated as potential risk factors for IPPB. IPPB was defined as a bleeding occurring during the procedure and was graded as G1-G4. Risk factors associated with IPPB were analyzed by univariate and multivariate logistic regression analysis. RESULTS A total of 9,336 colonic polyps were removed in 5,152 patients, and 262 (2.8%) colorectal polyps in 215 patients presented with IPPB. Polyp-based multivariate analysis revealed that old age (>or=65 yr), comorbid cardiovascular or chronic renal disease, anticoagulant use, polyp size greater than 1 cm, gross morphology of polyps such as pedunculated polyp or laterally spreading tumor, poorer bowel preparation, cutting mode of the electrosurgical current, and the inadvertent cutting of a polyp before current application were significant risk factors for IPPB. CONCLUSION Nine factors have been found to be associated with IPPB and polypectomy should be undertaken with caution under these conditions.
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Affiliation(s)
- Hyun S Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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Makar GA, Ginsberg GG. Therapy Insight: approaching endoscopy in anticoagulated patients. ACTA ACUST UNITED AC 2006; 3:43-52. [PMID: 16397611 DOI: 10.1038/ncpgasthep0387] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 11/04/2005] [Indexed: 12/31/2022]
Abstract
Over the past decade, the application of anticoagulant and antiplatelet agents for various cardiovascular and hematologic conditions has become more widespread. Optimal management of these agents during the periendoscopic period requires consideration, but limited prospective data mean that guidelines have largely relied on expert opinion. Elective procedures should be delayed in patients on temporary anticoagulation therapy (e.g. those with deep vein thrombosis). For procedures considered to have a low risk of bleeding (e.g. diagnostic endoscopy and colonoscopy without polypectomy) there is no need to discontinue or adjust anticoagulation. For procedures with a higher risk of bleeding (e.g. polypectomy and biliary sphincterotomy) an individual approach is required. This approach might include stopping oral anticoagulant therapy with or without the administration of unfractionated heparin or low-molecular-weight heparin for the preprocedure and postprocedure periods, during which the patient's international normalized ratio is in the subtherapeutic range.
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Affiliation(s)
- George A Makar
- Gastroenterology Division, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Komatsu T, Tamai Y, Takami H, Yamagata K, Fukuda S, Munakata A. Study for determination of the optimal cessation period of therapy with anti-platelet agents prior to invasive endoscopic procedures. J Gastroenterol 2005; 40:698-707. [PMID: 16082586 DOI: 10.1007/s00535-005-1613-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Accepted: 03/11/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anti-platelet agents are widely used for the treatment and prevention of thrombotic diseases. On the other hand, continuation of anti-platelet agents increases the risk of hemorrhagic complications in gastrointestinal endoscopy, and cessation of anti-platelet agents exposes the patient to the risk of thromboembolism. Only a few studies have actually studied the whether a cessation period is required prior to endoscopic procedures and if so, the optional duration of the period. The present study assessed the time course of primary hemostasis after the cessation of anti-platelet agents. METHODS Eleven healthy men (age range, 19-29 years) were assigned to each of the following regimens: aspirin (ASA; 100 mg/day), ticlopidine (TP; 300 mg/day), and a combination of ASA (100 mg/day) and TP (300 mg/day) for 7 days. There was a washout period of more than 3 weeks between each regimen. A quantitative bleeding time test (QBT test) and platelet aggregation test were performed before the beginning of administration, on the last day of administration, and at 1, 3, and 5 days after cessation, and also at 7 days after cessation for the combination regimen. RESULTS The average bleeding time (BT) and total bleeding loss volume (Tv) of the 11 subjects after administration of the three regimens were significantly increased compared with those before administration. With the administration of ASA, increases of BT and Tv at 3 days after cessation were not significant. The Tv at 5 days after cessation of TP was not significantly increased. With the combination regimen, the BT and Tv at 7 days after cessation were not significantly increased. CONCLUSIONS A 3-day cessation period for ASA, a 5-day cessation period for TP, and a 7-day cessation period for ASA+TP administration seem to be sufficient.
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Affiliation(s)
- Tomoko Komatsu
- The First Department of Internal Medicine, Hirosaki University School of Medicine, 5 Zaifucho, Hirosaki, 036-8562, Japan
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Yousfi M, Gostout CJ, Baron TH, Hernandez JL, Keate R, Fleischer DE, Sorbi D. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol 2004; 99:1785-9. [PMID: 15330919 DOI: 10.1111/j.1572-0241.2004.30368.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Limited data exist on the role of aspirin in increasing the risk of clinically significant postpolypectomy bleeding (PPB), which is defined as lower gastrointestinal (GI) hemorrhage following colonoscopic polyp removal requiring transfusion, hospitalization, endoscopic intervention, angiography, or surgery. OBJECTIVES To determine if aspirin use prior to colonoscopy increases the risk of clinically significant PPB. METHODS A case-control study of patients with clinically significant PPB at Mayo Clinic Scottsdale and Rochester was performed. Information collected included age, gender, recent use of aspirin or NSAIDs (within three days of colonoscopy), polyp characteristics, and polypectomy technique. The control group consisted of patients matched for age (+/-3 yr), gender, and cardiovascular morbidity who had undergone polypectomy without any complications. The populations were compared to determine the odds ratio (OR) of PPB with aspirin use. RESULTS During the study period, 20,636 patients underwent colonoscopy with polypectomy at the two institutions and 101 patients presented with clinically significant PPB. Twenty patients were excluded from analysis because of prior anticoagulant use. The remaining 81 patients were matched to 81 patients who had undergone colonoscopy without complications. The two groups were comparable in terms of polyp size (97%< or = 10 mm, bleeding group; 95%< or = 10 mm, control group). Aspirin use prior to polypectomy was 40% in the bleeding group and 33% in the control group (OR 1.41; 95% C.I. 0.68 to 3.04). CONCLUSION Postpolypectomy bleeding is an uncommon but important complication of endoscopic polypectomy. There was no statistically relevant difference in prior aspirin use before polypectomy in the bleeding group and the matched controls.
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Affiliation(s)
- Mahmoud Yousfi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
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20
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Hui AJ, Wong RMY, Ching JYL, Hung LCT, Chung SCS, Sung JJY. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 2004; 59:44-8. [PMID: 14722546 DOI: 10.1016/s0016-5107(03)02307-1] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anticoagulants and antiplatelet agents commonly are used to treat patients with cardiovascular and cerebrovascular diseases. Data on the safety of the use of these drugs before colonoscopic polypectomy are scanty. METHODS An audit was conducted for a 2-year period of consecutive patients undergoing colonoscopy and polypectomy. Patient demographics, site and size of polyps, and the use of anticoagulants and antiplatelet agents were documented from a hospital on-line database. Bleeding episodes were classified as immediate or delayed and were graded as mild, moderate, or severe. Risk factors associated with postendoscopy bleeding were analyzed by multivariate logistic regression analysis. RESULTS A total of 5593 cases were reviewed. Polypectomy was performed in 1657 patients. There were 37 cases of polypectomy-associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use, after adjustment for the effects of each of the other factors, was an independent risk factor for bleeding, with an odds ratio 13.37: 95% CI[4.10, 43.65]. Age; the location and size of polyp; and the use of aspirin, non-steroidal anti-inflammatory drugs, and other antiplatelet agents were not associated with a higher risk of polypectomy-associated bleeding. CONCLUSIONS The use of antiplatelet agents during polypectomy was not associated with an increase in post-polypectomy bleeding. In contrast, treatment with warfarin should be discontinued, because this was associated with a significant increase in post-polypectomy bleeding.
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Affiliation(s)
- Aric J Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
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Abstract
BACKGROUND The management of patients taking aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) who require colonoscopy remains controversial because of concerns over bleeding after biopsy or polypectomy. AIM To determine whether patients using the NSAID nabumetone, a non-acidic prodrug with mixed activity against cyclooxygenase-1 (COX-1) and COX-2, exhibited prolonged mucosal bleeding times and how this might compare with mucosal bleeding times in patients using aspirin. METHODS We assessed triplicate mucosal bleeding times in patients undergoing screening flexible sigmoidoscopy. We compared 90 patients who had taken no aspirin or NSAIDs within the previous 2 weeks, to 60 patients who had received nabumetone 1 g b.d. by mouth for the previous 2 weeks, and 30 patients who had taken 325 mg aspirin daily for the previous 2 weeks. In each case, the investigator performing the study was blinded to the patient's medication. RESULTS Mucosal bleeding times did not differ significantly among control or nabumetone-using patients. However, the patients receiving aspirin exhibited significant prolongation. Mucosal bleeding time correlated statistically significantly, but weakly, with skin bleeding time. CONCLUSIONS Nabumetone does not appear to prolong mucosal bleeding time after mucosal pinch biopsy, and skin bleeding time does not reliably screen for prolonged mucosal bleeding time.
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Affiliation(s)
- M D Basson
- Wayne State University Medical School, Detroit, MI, USA.
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Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51:690-6. [PMID: 10840301 DOI: 10.1067/mge.2000.105773] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postpolypectomy hemorrhage may warrant intensive care monitoring, transfusions, and surgery. We sought factors predicting significant bleeding requiring blood transfusion and the benefits of critical care monitoring. METHODS Patients with postpolypectomy bleeding between April 1989 and November 1996 were identified from a comprehensive GI bleeding database. Data included age, gender, medical history, medications, polyp characteristics, and polypectomy technique. Outcomes assessed included bleeding cessation, transfusion requirements, recurrent bleeding, length of stay, and death. RESULTS There were 83 patients with a median age of 73 years (range 18 to 88 years; 56 men, 27 women). Comorbid conditions were common (71.1% cardiovascular, 43.4% musculoskeletal, 14.5% hematologic, 6.0% renal). Within 3 days of presentation, 32.5% had taken aspirin, 10.8% nonsteroidal anti-inflammatory drugs, 12.0% warfarin, and 12.0% corticosteroids; and within 1 day, 10.8% intravenous heparin, 7.2% subcutaneous heparin, and 7.2% dipyridamole. Fifty-seven percent of patients were hemodynamically stable. Sessile cecal polyps greater than 2 cm in diameter bled more commonly. The median number of units transfused was equal between critical care and noncritical care patients. Using age in the logistic regression model, no other variable was predictive of transfusion. Eighty patients (96.4%) received endoscopic therapy, 1 required embolization and 2 hemicolectomy. There was no significant difference in outcomes for patients managed in an intensive care unit versus a general medical floor. CONCLUSIONS Postpolypectomy bleeding appears to have a predictable presentation and outcome. Advanced age seems to be predictive of transfusion requirement. Patient monitoring in an intensive care setting is not absolutely necessary.
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Affiliation(s)
- D Sorbi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Cappell MS, Abdullah M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol Clin North Am 2000; 29:125-67, vi-vii. [PMID: 10752020 DOI: 10.1016/s0889-8553(05)70110-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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Parra-Blanco A, Kaminaga N, Kojima T, Endo Y, Uragami N, Okawa N, Hattori T, Takahashi H, Fujita R. Hemoclipping for postpolypectomy and postbiopsy colonic bleeding. Gastrointest Endosc 2000; 51:37-41. [PMID: 10625793 DOI: 10.1016/s0016-5107(00)70384-1] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Obtaining colonoscopic biopsies and polypectomy can result in hemorrhage. The most effective management of this complication has not been determined. The objective of this study was to evaluate the endoscopic hemoclip in postprocedural colonic bleeding. METHODS Among 9555 consecutive colonoscopies, cases of postprocedural colonic bleeding (postpolypectomy and postbiopsy) requiring treatment were retrospectively reviewed. Endoscopic hemoclipping was initially attempted in each case; the rate of hemostasis after hemoclipping, use of additional hemostatic methods, and clinical outcome (need for transfusion/hospitalization) were analyzed. RESULTS There were 72 cases of bleeding in which treatment was required (45 immediate postpolypectomy, 18 delayed postpolypectomy and 9 postbiopsy). Endoscopic hemostasis was achieved in all cases of immediate postpolypectomy and postbiopsy bleeding and in all but one of the cases with delayed postpolypectomy bleeding. A detachable snare was used in addition to hemoclips in 3 cases of delayed postpolypectomy bleeding. There were no episodes of recurrent bleeding, deaths or need for surgery related to bleeding. CONCLUSION Early endoscopic management of postprocedural bleeding by hemoclipping provides hemostasis in the great majority of cases.
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Affiliation(s)
- A Parra-Blanco
- Division of Gastroenterology, Endoscopy Unit, Fujigaoka Hospital, Showa University, Yokohama, Japan
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