Thinking Outside the Box
Colonoscopy with polypectomy in anticoagulated patients

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Background

According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known.

Objective

Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated.

Design

Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation.

Setting

Veterans Administration Palo Alto Health Care System.

Patients

Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm).

Interventions

All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding.

Main Outcome Measurements

Rate of postpolypectomy bleeding.

Results

There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient.

Limitations

Small single-center retrospective study.

Conclusions

Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

Section snippets

Methods

We retrospectively reviewed our experience from July 2004 to August 2005 in performing colonoscopy with polypectomy in patients receiving long-term anticoagulation therapy at the Veterans Affairs Palo Alto Health Care System. Informed consent for the procedure was obtained from all patients, including discussion of the potentially high risk of bleeding as a result of anticoagulation. Institutional Review Board approval was obtained for retrospective data analysis. All patients undergoing

Results

Twenty-one patients underwent a total of 41 colonoscopic polypectomies during the study period. The average INR on the day of the procedure was 2.3 (SD 0.8, range 1.4-4.9, median 2.0; normal 0.9-1.2). The average polyp size was 5.0 mm (SD 1.5 mm, range 3-10 mm). Immediately after polypectomy, 1 or 2 endoclips were placed prophylactically to close the polypectomy defect. Because this was typically done within 1 minute of the polypectomy, no more than minimal (<10 mL) bleeding occurred in any of

Discussion

Postpolypectomy bleeding is generally divided into 2 types: immediate bleeding after the polypectomy and delayed bleeding that can occur up to 2 to 3 weeks after the procedure.8, 9 Immediate bleeding is particularly common after endoscopic mucosal resection of large sessile polyps, and it is generally effectively treated by expert endoscopists using established techniques such as clipping.10, 11 In patients who require long-term anticoagulation, all the published guidelines recommend temporary

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