Gastroenterological procedures among patients with disorders of hemostasis: evaluation and management recommendations☆,☆☆,★
Section snippets
Endoscopic biopsy and polypectomy
In the absence of coagulation disorders, the risk of bleeding after a “cold” mucosal biopsy is negligible. Forceps-type biopsies are superficial and limited to the mucosa and microvessels (capillaries and venules). However, the bleeding risk after polypectomy (including electrosurgical snare excision and electrocoagulation/biopsy) is higher at approximately 0.4% to 1.6%,2, 3 presumably because of transection of an arteriole in the stalk of the polyp. Pre-procedure screening assays of hemostasis
Prothrombin time
The prothrombin time (PT) tests the extrinsic (tissue factor) and common procoagulant pathways, including fibrinogen (factor I), and procoagulant factors II, V, VII, and X. The PT assay is performed by the addition of tissue thromboplastin (tissue factor) and calcium to citrated plasma followed by measurement of the clotting time in seconds. The PT most frequently is used to screen for congenital factor deficiency or vitamin K deficiency, to test for the coagulopathy associated with liver
Bleeding history
The bleeding history is the most sensitive and cost-effective means of identifying patients at risk for bleeding.11 Assessment of the patient’s response to a previous hemostatic challenge is the most important aspect of the bleeding history. Patients who have undergone major surgery or experienced severe trauma without abnormal bleeding are unlikely to have a clinically significant bleeding disorder. Inquiry regarding epistaxis, gingival bleeding, ecchymoses, petechiae, hemoptysis, hematemesis,
INHERITED DISORDERS OF HEMOSTASIS
A detailed discussion of the inherited disorders of hemostasis is beyond the scope of this article. Thus, the pathophysiology and clinical features of these disorders are mentioned only in brief in this section.
MANAGEMENT OF PATIENTS WITH INHERITED DISORDERS OF HEMOSTASIS
Patients with inherited bleeding disorders which are sufficiently severe as to require factor replacement therapy should be managed in consultation with an experienced hematologist and preferably within a tertiary care institution with a hemophilia center. These patients require specialized care, including special coagulation laboratory facilities which can provide the rapid factor assays needed to adjust factor replacement therapy, as well as a blood bank/transfusion therapy unit experienced
Aspirin, NSAID use and other acquired disorders of platelet function
Aspirin-induced excessive intraoperative or postoperative bleeding is of marginal clinical significance in most patients.18 For this reason, therapeutic procedures can be carried out even if a patient has taken aspirin within 1 week before the procedure. Aspirin can be continued after therapeutic procedures, though overly cautious physicians may tell their patients not to take aspirin for 7 to10 days after the procedure. The policy is the same for NSAIDs with the exception that the half-life of
CONCLUSIONS
The management of patients with disorders of hemostasis before endoscopic procedures continues to pose a clinical challenge. The clinical data regarding bleeding complications after gastroenterologic procedures performed in the setting of coagulation disorders are limited. An understanding of the various coagulation tests and the common coagulation disorders is essential for the GI endoscopist considering invasive procedures on these patients. A history suggestive of a bleeding disorder is
Acknowledgements
We thank Linda Veer for expert secretarial assistance.
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Supported, in part, by the U.S. Public Health Service (TS-102), and by the Mayo Foundation.
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Reprint requests: Patrick S. Kamath, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905.
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