Colonoscopy, Polypectomy, and the Risk of Bleeding

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Key points

  • There is no need to withdraw cardioprotective aspirin for polypectomy.

  • Avoid withdrawing either aspirin or thienopyridines within 30 days of cardiac stenting and consider postponing elective colonoscopy up to 12 months if feasible after placement of drug-eluting stents.

  • If feasible, consider postponing elective colonoscopy until short-term anticoagulant treatment is completed.

  • Do not withdraw antiplatelets or anticoagulants for low-risk bleeding procedures (ie, diagnostic colonoscopy with no

Risks of colonoscopy

Although colonoscopy is generally considered a safe procedure, it is not without risks. Risks of colonoscopy include perforation, hemorrhage, complications of sedation, postpolypectomy coagulation syndrome, and (rarely) splenic rupture (Table 1). Indeed, colonoscopic complications (particularly perforation or hemorrhage) occur most commonly in patients who undergo polypectomy.2 Hemorrhage after removal of a polyp, termed postpolypectomy bleeding (PPB), can occur in 1 of 2 forms: immediate PPB

Risk factors for postpolypectomy bleeding

Polyp factors, patient factors, and even physician factors have been associated with an increased risk of immediate and/or delayed PPB.7, 8, 9, 10 Polyp-related factors include polyp size, polyp morphology, and polyp location in the colon. One of the major polyp-related risk factors for PPB is polyp size. In a study investigating pedunculated polyps, the PPB rate (immediate or delayed) for 98 polyps that were 1 to 1.9 cm was 3.1%, whereas PPB occurred in 15.1% of 66 polyps 2 cm or greater.11 In

Outcomes of patients with postpolypectomy bleeding

Fortunately, for patients who do experience PPB, this complication is not typically associated with any major long-term sequelae. In a study of 1657 subjects undergoing polypectomy, there were 5 with delayed PPB, all of whom received blood transfusion. Four of the 5 were treated successfully endoscopically, and PPB was controlled in the fifth with angiography after endoscopic treatment had failed. None of these subjects required surgery and none died of PPB.20 In the author’s study,

Considerations when referring patients for colonoscopy

When referring patients for colonoscopy, it is very important to carefully evaluate their regimen of antiplatelets or anticoagulants and the timing of the colonoscopy. The use of antiplatelets and anticoagulants is increasing given the high rates of coronary artery disease and cerebrovascular disease in the United States. The American Heart Association estimates that 83.6 million American adults have some form of cardiovascular disease, including approximately 15.4 million with coronary artery

Managing aspirin in the periprocedural period

Aspirin irreversibly acetylates and inactivates the platelet cyclooxygenase, thereby inactivating platelets for the duration of their lifespan, 7 to 10 days. Nevertheless, based on several retrospective studies,13, 20, 22 guidelines agree that aspirin can be safely continued during colonoscopy with polypectomy without concern for a significant increase in bleeding.23, 24, 25 Moreover, the cardiovascular risks associated with withdrawing aspirin can be high, especially in patients with a history

Managing thienopyridines in the periprocedural period

The thienopyridines inhibit platelet function by blocking adenosine diphosphate, which interferes with the platelets’ ability to aggregate. In patients with coronary artery disease, especially in the setting of coronary stents, thienopyridines are most frequently given in combination with aspirin, which is termed dual antiplatelet therapy (DAPT). For patients on continued thienopyridines during polypectomy, prospective data found the rate of PPB to be 2.4% and interestingly, all patients with

Managing warfarin in the periprocedural period

Warfarin is a commonly used anticoagulant agent that works by inhibiting vitamin K–dependent coagulation factor synthesis. This drug is used for treatment of a variety of disorders, including deep vein thrombosis (DVT); pulmonary embolism; ischemic stroke; and prophylaxis of arterial thromboembolism from atrial fibrillation, flutter, and cardiac valvular disorders. It is important to remember that, although the goal with interrupting anticoagulants periprocedurally is to reduce the risk of

Managing direct-acting oral anticoagulants in the periprocedural period

The direct-acting oral anticoagulants (DOACs) include the direct thrombin inhibitor, dabigatran; and the factor Xa inhibitors, rivaroxaban, apixaban, edoxaban, and betrixaban. Additionally, there are subcutaneous and intravenous direct thrombin inhibitors and factor Xa inhibitors (Table 2); however, this article focuses on the oral agents because they are the drugs most likely to be encountered in the setting of elective colonoscopy. The major advantages of the DOACs compared with warfarin are

When to readminister drugs after the procedure

After making the decision to discontinue an antiplatelet or anticoagulant in preparation for an endoscopic procedure, the next important decision is when to readminister the drug after the procedure. Unfortunately, the guidelines provide no clear consensus because there are very few studies on which to base the recommendations. For thienopyridines, the ACC/ACG (the joint guidelines from the American College of Cardiology and American College of Gastroenterology) recommend readministering “as

Summary

Colonoscopy with polypectomy is the means by which the incidence of colon cancer may be reduced; however, polypectomy is not without risk. Physicians must carefully weigh the risks and benefits of colonoscopy, particularly when patients are prescribed antiplatelet agents and anticoagulants. Aspirin and NSAIDs can be continued safely during colonoscopy with polypectomy. The risk of delayed PPB is increased if thienopyridines are continued and is increased even if warfarin therapy is interrupted.

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  • Cited by (8)

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      The following qualifying remarks apply to this empiric risk classification: Selected minimal-bleed-risk procedures may require 1 to 2 days of anticoagulant interruption if there is concern about bleeding: for example, a dental extraction may be more complex in a patient with poor dentition or compromised gingival integrity53; a screening colonoscopy in patients with a history of polyps that may require resection54; and coronary angiography with a femoral (instead of radial) artery access.48 Surgical procedures (eg, an inguinal hernia repair55) may vary widely in complexity and might be justifiably categorized as low-to-moderate- or high-bleed-risk.

    • Managing bleeding risk after cold snare polypectomy in patients receiving direct-acting oral anticoagulants

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      However, the proportion of patients receiving each type of DOACs in immediate bleeding was not significantly different in either group (Table 4). Although immediate postpolypectomy bleeding was more frequent than the previously assumed 1% to 2% associated with conventional polypectomy of a lesion >1 cm in a patient not on antithrombotic agents,15 differences may relate to definitions of immediate bleeding. In this study immediate bleeding was defined as spurting or oozing that continued for more than 60 seconds.

    • Antiplatelets, anticoagulants, and colonoscopic polypectomy

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      Removing lesions ≥1 cm is associated with a 1% to 2% PPB rate related to inadequate cauterization of underlying small vessels (immediate bleeding)8 or thermal injuries causing ulceration and delayed bleeding.2 Choice of electrocautery (pure-cut rather than blend-current), patient age (>65 years), polyp morphology, and antithrombotic agents also increase PPB.8,12 Nonthermal polypectomy of small lesions (≤1 cm) is believed to be associated with a lesser risk (<1%) given the absence of thermal injury related to cautery.

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    Dr. Feagins current research is funded by a VA CSR&D MERIT Award grant number 5I01CX00815.

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