Management of Anticoagulants and Antiplatelet Agents During Colonoscopy

Curable giant hematoma due to small bowel mesenteric laceration after screening colonoscopy: a case report

Introduction and importance

Mesenteric laceration after screening colonoscopy is a rare and fatal complication. This case reported a giant hematoma due to a small intestinal mesenteric laceration after a screening colonoscopy.

Case description

A 56-year-old woman complained of persistent dramatic abdominal pain after the screening colonoscopy. This patient has appendectomy, rheumatic heart disease, IgG4-related disease, type 2 diabetes mellitus, and coronary atherosclerotic heart disease. Blood tests showed hemoglobin concentration sharply fell to 87 g/L and computed tomography scans confirmed a 16.4 cm × 6.1 cm × 9.5 cm hematoma abdominal hematoma near the small intestine. Digital subtraction angiography consistently showed rough and disordered the fourth group of the superior mesenteric artery. The main diagnosis was mesenteric laceration of the small intestine following colonoscopy. The patient was treated with fasting, gastrointestinal decompression, rehydration, inhibition of gastric acid, and meropenem to fight infection, 4 U suspended red blood cells and 400 mL fresh frozen plasma. Finally, this patient was discharged after conservative treatment, and the abdominal hematoma was significantly shrunk after 3 months.

Clinical discussion

Anticoagulants, a history of previous abdominal surgery, and IgG-RD leading to abdominal fibrosis were possible risk factors for mesenteric laceration. When the patient's condition is complex and has no absolute indication for surgery, conservative management could be appropriately considered.

Conclusions

We reported a case of abdominal hematoma due to colonoscopy. The successful conservative therapy may provide a novel experience for intra-abdominal hematoma treatment.

Risk of Delayed Bleeding after Cold Snare Polypectomy in Patients with Antithrombotic Therapy

BACKGROUND

Cold snare polypectomy is being increasingly adopted; however, there are few reports of cold snare polypectomy regarding antithrombotic therapy.

AIMS

This study aimed to investigate the real-world safety of cold snare polypectomy during antithrombotic therapy.

METHODS

We collected data from consecutive patients undergoing cold snare polypectomy in a single hospital between 2013 and 2017. Indications for cold snare polypectomy were any ≤ 10 mm polyp. The primary outcome was delayed bleeding. We compared rates of delayed bleeding between patients with and without antithrombotic therapy and analyzed risk factors for delayed bleeding using binary logistic regression model with firth procedure.

RESULTS

In 2152 patients (mean age 67.6 years; male 1411), 4433 colorectal polyps (mean diameter 5.0 mm) underwent cold snare polypectomy. Clipping during the procedure was performed for 5.8%. Delayed bleeding occurred in 0.51% (11/2152) of patients and 0.25% (11/4433) of polyps, but no major delayed bleeding occurred. A total of 244 (11%) patients received antithrombotic therapy. Patients on antithrombotic therapy were older (p < 0.001), more likely male (p < 0.001) and had cold snare polypectomy in the proximal colon (p = 0.011). The rate of delayed bleeding was higher in patients on antithrombotic therapy (1.64% vs. non-antithrombotic therapy 0.37%, p = 0.009). Larger polyp size (> 5 mm), use of clips, and antithrombotic therapy were significant risk factors for delayed bleeding. There was no clear association between specific antithrombotic agents and delayed bleeding.

CONCLUSIONS

Delayed bleeding after cold snare polypectomy was rare even in patients with antithrombotic therapy, and no major delayed bleeding occurred.

Risk of colonoscopic post-polypectomy bleeding in patients on single antiplatelet therapy: systematic review with meta-analysis

BACKGROUND

It was not yet fully established whether the use of antiplatelet agents (APAs) is associated with an increased risk of colorectal post-polypectomy bleeding (PPB). Temporarily, discontinuation of APAs could reduce the risk of PPB, but at the same time, it could increase the risk of cardiovascular disease recurrence. This study aimed to assess the PPB risk in patients using APAs compared to patients without APAs or anticoagulant therapy who had undergone colonoscopy with polypectomy.

METHODS

A systematic electronic search of the literature was performed using PubMed/MEDLINE, Scopus, and CENTRAL, to assess the risk of bleeding in patients who do not interrupt single antiplatelet therapy (P2Y12 inhibitors or aspirin) and undergone colonoscopy with polypectomy.

RESULTS

Of 2417 identified articles, 8 articles (all of them were non-randomized studies of interventions (NRSI); no randomized controlled trials (RCT) were available on this topic) were selected for the meta-analysis, including 1620 patients on antiplatelet therapy and 13,321 controls. Uninterrupted APAs single therapy was associated with an increased risk of PPB compared to the control group (OR 2.31; CI 1.37-3.91). Patients on P2Y12i single therapy had a higher risk of both immediate (OR 4.43; CI 1.40-14.00) and delayed PPB (OR 10.80; CI 4.63-25.16) compared to the control group, while patients on aspirin single therapy may have a little to no difference increase in the number of both immediate and delayed PPB events.

CONCLUSIONS

Uninterrupted single antiplatelet therapy may increase the risk of PPB, but the evidence is very uncertain. The risk may be higher in delayed PPB. However, in deciding to discontinue APAs before colonoscopy with polypectomy, the potential higher risk of major adverse cardiovascular events should always be assessed.

Thoughts on factors related to colonoscopy quality

With the increase in health consciousness and the prevalence of early gastrointestinal cancer screening, the number of diagnosed cases of colorectal polyps and adenomas in the Chinese general population has substantially increased. However, the overall adenoma detection rate (ADR) in China remains lower than the global standard of 30%. High quality colonoscopy is pivotal for increasing the ADR and reducing the risk of interval colon cancer. A few factors are related to the quality of colonoscopy, including preoperative evaluation of examinees, bowel preparation, techniques for intubation, use of image enhancement endoscopy, withdraw time, and prevention of adverse events.

Novel Oral Anticoagulants in the Peri-Endoscopic Period

Millions of patients in the United States are currently prescribed some form of anticoagulation therapy. Recently, novel oral anticoagulants (NOACs), including direct thrombin inhibitors and direct factor Xa inhibitors, have begun to replace warfarin as the drugs of choice for anticoagulation. As the use of these medications becomes more widespread, it is increasingly important for gastroenterologists to understand the risks associated with performing endoscopic procedures on patients who are taking NOACs. In this review, we provide an overview of the NOACs and current guidelines from international societies regarding the management of patients scheduled to undergo endoscopic procedures who are prescribed these medications. Finally, we offer a perspective on future studies required to adequately investigate and characterize the effects that these drugs have on a patient's risk for bleeding in the peri- and/or postprocedural timeframes.