The risk of post-polypectomy bleeding among patients receiving antithrombotic agents
A prospective observational study
Keywords:
Colonoscopy, Hemorrhage, Colonic polypsAbstract
BACKGROUND: In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES: The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING: Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS: Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients’ data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size,polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and com- plications relating to the procedures were recorded. RESULTS: The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION: This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.
Downloads
References
Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687-96. PMID: 22356322; http://doi.org/10.1056/NEJMoa1100370.
Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63(4):546-57. PMID: 16564851; http://doi.org/10.1016/j.gie.2006.02.002.
Guseinova Z, Taizhanova D, Tauesheva Z, et al. Efficiency of screening research in prevention and early diagnostics of sporadical colorectal cancer. Acta Medica Mediterranea. 2019;35:757. http://doi.org/10.19193/0393-6384_2019_2_114.
Watabe H, Yamaji Y, Okamoto M, et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc. 2006;64(1):73-8. PMID: 16813806; http://doi.org/10.1016/j.gie.2006.02.054.
Bozkurt H, Ölmez T, Bulut Cİ, et al. The safety of upper gastrointestinal endoscopic biopsy in patients receiving antithrombic drugs. A single-centre prospective observational study. Gastroenterology Rev. 2020;15(3):234-40. http://doi.org/10.5114/pg.2019.88622.
Van Overbeke L, Ilegems S, Mertens G, et al. Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm. A retrospective series. Acta Gastroenterol Belg. 2019;82(4):475-8. PMID: 31950801.
Mabe K, Kato M, Oba K, et al. A prospective, multicenter survey on the validity of shorter periendoscopic cessation of antithrombotic agents in Japan. J Gastroenterol. 2017;52(1):50-60. PMID: 27085338; http://doi.org/10.1007/s00535-016-1203-3.
Hallas J, Dall M, Andries A, et al. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. BMJ. 2006;333(7571):72610. PMID: 16984924; http://doi.org/10.1136/bmj.38947.697558.AE.
Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2008;118(18):1894-909. PMID: 18836135; http://doi.org/10.1161/CIRCULATIONAHA.108.191087.
Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation. 2012;126(11):1355-62. PMID: 22893606; http://doi.org/10.1161/CIRCULATIONAHA.112.102715.
Fujimoto K, Fujishiro M, Kato M, et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26(1):1-14. PMID: 24215155; http://doi.org/10.1111/den.12183.
Participantes do Workshop de Paris. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc. 2003;58(6 Suppl):S3-43. PMID: 14652541; http://doi.org/10.1016/s0016-5107(03)02159-x.
Ishigami H, Arai M, Matsumura T, et al. Heparin-bridging therapy is associated with a high risk of post-polypectomy bleeding regardless of polyp size. Dig Endosc. 2017;29(1):65-72. PMID: 27368065; http://doi.org/10.1111/den.12692.
Basson MD, Panzini L, Palmer RH. Effect of nabumetone and aspirin on colonic mucosal bleeding time. Aliment Pharmacol Ther. 2001;15(4):539-42. PMID: 11284783; http://doi.org/10.1046/j.1365-2036.2001.00948.x.
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; http://doi.org/10.1186/1471-230X-12-138.
ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70(6):1060-70. PMID: 19889407; http://doi.org/10.1016/j.gie.2009.09.040.
Boustière C, Veitch A, Vanbiervliet G, et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2011;43(5):445-61. PMID: 21547880; http://doi.org/10.1055/s-0030-1256317.
Yousfi M, Gostout CJ, Baron TH, et al. Post-polypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol. 2004;99(9):1785-9. PMID: 15330919; http://doi.org/10.1111/j.1572-0241.2004.30368.x.
Manocha D, Singh M, Mehta N, Murthy UK. Bleeding risk after invasive procedures in aspirin/NSAID users: polypectomy study in veterans. Am J Med. 2012;125(12):1222-7. PMID: 23164486; http://doi.org/10.1016/j.amjmed.2012.05.030.
Gandhi S, Narula N, Mosleh W, Marshall JK, Farkouh M. Meta-analysis: colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy. Aliment Pharmacol Ther. 2013;37(10):947-52. PMID: 23530880; http://doi.org/10.1111/apt.12292.
Chan FKL, Kyaw MH, Hsiang JC, et al. Risk of Post-polypectomy Bleeding With Uninterrupted Clopidogrel Therapy in an Industry-Independent, Double-Blind, Randomized Trial. Gastroenterology. 2019;156(4):918-25. PMID: 30518511; http://doi.org/10.1053/j.gastro.2018.10.036.
Singh M, Mehta N, Murthy UK, Newman N, et al. Post-polypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc. 2010;71(6):998-1005. PMID: 20226452; http://doi.org/10.1016/j.gie.2009.11.022.
ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16. PMID: 26621548; http://doi.org/10.1016/j.gie.2015.09.035.
Veitch AM, Vanbiervliet G, Gershlick AH, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2016;48(4):385-402. PMID: 26890676; http://doi.org/10.1016/j.gie.2015.09.035.
Kubo T, Yamashita K, Onodera K, et al. Heparin bridge therapy and post-polypectomy bleeding. World J Gastroenterol. 2016;22(45):10009-14. PMID: 28018108; http://doi.org/10.3748/wjg.v22.i45.10009.
Inoue T, Nishida T, Maekawa A, et al. Clinical features of post-polypectomy bleeding associated with heparin bridge therapy. Dig Endosc. 2014;26(2):243-9. PMID: 23730922; http://doi.org/10.1111/den.12123.
Siegal D, Yudin J, Kaatz S, et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation. 2012;126(13):1630-9. PMID: 22912386; http://doi.org/10.1161/CIRCULATIONAHA.112.105221.
Sakai T, Nagami Y, Shiba M, et al. Heparin-bridging therapy is associated with post-colorectal polypectomy bleeding in patients whose oral anticoagulation therapy is interrupted. Scand J Gastroenterol. 2018;53(10-11):1304-10. PMID: 30345853; http://doi.org/10.1080/00365521.2018.1503325.
Shalman D, Gerson GB. Systematic review with meta-analysis: the risk of gastrointestinal haemorrhage post-polypectomy in patients receiving anti-platelet, anti-coagulant and/or thienopyridine medications. Aliment Pharmacol Ther. 2015;42(8):949-56. PMID: 26290157; http://doi.org/10.1111/apt.13367.
Pigò F, Bertani H, Grande G, et al. Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis. Dig Liver Dis. 2018;50(1):20-6. PMID: 29089272; http://doi.org/10.1016/j.dld.2017.10.005
