1
|
Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
Collapse
Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Gornick D, Kadakuntla A, Trovato A, Stetzer R, Tadros M. Practical considerations for colorectal cancer screening in older adults. World J Gastrointest Oncol 2022; 14:1086-1102. [PMID: 35949211 PMCID: PMC9244986 DOI: 10.4251/wjgo.v14.i6.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/23/2022] [Accepted: 04/30/2022] [Indexed: 02/06/2023] Open
Abstract
Recent guidelines recommend that colorectal cancer (CRC) screening after age 75 be considered on an individualized basis, and discourage screening for people over 85 due to competing causes of mortality. Given the heterogeneity in the health of older individuals, and lack of data within current guidelines for personalized CRC screening approaches, there remains a need for a clearer framework to inform clinical decision-making. A revision of the current approach to CRC screening in older adults is even more compelling given the improvements in CRC treatment, post-treatment survival, and increasing life expectancy in the population. In this review, we aim to examine the personalization of CRC screening cessation based on specific factors influencing life and health expectancy such as comorbidity, frailty, and cognitive status. We will also review screening modalities and endoscopic technique for minimizing risk, the risks of screening unique to older adults, and CRC treatment outcomes in older patients, in order to provide important information to aid CRC screening decisions for this age group. This review article offers a unique approach to this topic from both the gastroenterologist and geriatrician perspective by reviewing the use of specific clinical assessment tools, and addressing technical aspects of screening colonoscopy and periprocedural management to mitigate screening-related complications.
Collapse
Affiliation(s)
- Dana Gornick
- Albany Medical College, Albany Medical College, Albany, NY 12208, United States
| | - Anusri Kadakuntla
- Albany Medical College, Albany Medical College, Albany, NY 12208, United States
| | - Alexa Trovato
- Albany Medical College, Albany Medical College, Albany, NY 12208, United States
| | - Rebecca Stetzer
- Division of Geriatrics, Albany Medical Center, Albany, NY 12208, United States
| | - Micheal Tadros
- Division of Gastroenterology, Albany Medical Center, Albany, NY 12208, United States
| |
Collapse
|
3
|
Huang G, Tian FY, An W, Ai LS, Yu YB. Effects of antithrombotic therapy on bleeding after endoscopic sphincterotomy: A systematic review and meta-analysis. Endosc Int Open 2022; 10:E865-E873. [PMID: 35692927 PMCID: PMC9187383 DOI: 10.1055/a-1793-9479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/31/2022] [Indexed: 10/25/2022] Open
Abstract
Background and study aims Bleeding is a common complication of following endoscopy sphincterotomy (EST), and antithrombotic therapy use during the procedure often increases risk of it. Although several guidelines have been released regarding the use of antithrombotic agents during EST, many issues about it remain controversial. We carried out a systematic review and meta-analysis to evaluate the effect of antithrombotic medication on the risk of EST bleeding. Methods A structured literature search was carried out in Web of Science, EMBASE, PubMed, and Cochrane Library databases. RevMan 5.2 was used for meta-analysis to investigate the rate of post-EST bleeding. Results Seven retrospective articles were included. Compared with patients who had never taken antithrombotic drugs, patients who discontinued antithrombotic drugs 1 day before the procedure had a significantly increased risk of post-EST bleeding (OR, 1.95; 95 %CI, 1.57-2.43), particularly for severe bleeding (OR, 1.83; 95 %CI, 1.44-2.34). In addition, compared with patients who discontinued antithrombotic therapy for at least 1 day, patients who continued taking antithrombotic drugs did have an increased risk of post-EST bleeding (OR, 0.70; 95 %CI, 0.40-1.23). Conclusions The use of antithrombotic drugs may increase the bleeding rate of EST, but discontinuing therapy 1 day before endoscopy does not significantly reduce the bleeding rate.
Collapse
Affiliation(s)
- Gang Huang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Feng-Yu Tian
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Wen An
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Li-Si Ai
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Yan-Bo Yu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| |
Collapse
|
4
|
Goudreau S, Grimm LJ, Srinivasan A, Net J, Yang R, Dialani V, Dodelzon K. Bleeding Complications After Breast Core-needle Biopsy-An Approach to Managing Patients on Antithrombotic Therapy. JOURNAL OF BREAST IMAGING 2022; 4:241-252. [PMID: 38416973 DOI: 10.1093/jbi/wbac020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Indexed: 03/01/2024]
Abstract
Image-guided core-needle breast and axillary biopsy (CNB) is the standard-of-care procedure for the diagnosis of breast cancer. Although the risks of CNB are low, the most common complications include bleeding and hematoma formation. Post-procedural bleeding is of particular concern in patients taking antithrombotic therapy, but there is currently no widely established standard protocol in the United States to guide antithrombotic therapy management. In the face of an increasing number of patients taking antithrombotic therapy and with the advent of novel classes of anticoagulants, the American College of Radiology guidelines recommend that radiologists consider cessation of antithrombotic therapy prior to CNB on a case-by-case basis. Lack of consensus results in disparate approaches to patients on antithrombotic therapy undergoing CNB. There is further heterogeneity in recommendations for cessation of antithrombotic therapy based on the modality used for image-guided biopsy, target location, number of simultaneous biopsies, and type of antithrombotic agent. A review of the available data demonstrates the safety of continuing antithrombotic therapy during CNB while highlighting additional procedural and target lesion factors that may increase the risk of bleeding. Risk stratification of patients undergoing breast interventional procedures is proposed to guide both pre-procedural decision-making and post-procedural management. Radiologists should be aware of antithrombotic agent pharmacokinetics and strategies to minimize post-procedural bleeding to safely manage patients.
Collapse
Affiliation(s)
- Sally Goudreau
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, TX, USA
| | - Lars J Grimm
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | | | - Jose Net
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Roger Yang
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vandana Dialani
- Beth Israel Lahey Health, Department of Radiology, Boston, MA, USA
| | - Katerina Dodelzon
- Weill Cornell at New York-Presbyterian, Department of Radiology, New York, NY, USA
| |
Collapse
|
5
|
Zhao X, Huang Y, Li J, Zhou A, Chen G, Deng H. Management of anticoagulants in delayed bleeding after endoscopic resection: A systematic review and meta-analysis. Endosc Int Open 2021; 9:E1128-E1135. [PMID: 34222639 PMCID: PMC8216774 DOI: 10.1055/a-1467-6068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background and study aims Delayed bleeding and thrombotic events are uncontrolled adverse events that are hard to balance in patients receiving anticoagulants after endoscopic resection. The present study aims to assess the clinical effect of warfarin, when compared to direct oral anticoagulants (DOACs), in terms of delayed bleeding and thrombotic events. Methods A comprehensive electronic literature search was conducted for eligible literature. Pairwise meta-analyses were performed on outcomes of delayed bleeding and thrombotic events. Two networks within the Bayesian framework were established based on the management of anticoagulants and type of DOAC. Results Eight cohort studies with 2,046 patients were eligible for inclusion, including 1,176 patients treated with warfarin and 870 with DOACs. There was no significant difference between warfarin and DOACs, in terms of delayed bleeding (OR = 1.29, 95 % CI [0.99-1.69]) and thromboembolism (OR = 2.0, 95 % CI [0.32-12.39]). In the network meta-analyses for delayed bleeding, the rank probabilities revealed that the safest management was discontinuous warfarin without heparin bridge therapy (HBT). Rank probabilities for the types of DOACs demonstrated that the safest drug was dabigatran. Conclusions There was no significant difference in delayed bleeding and thromboembolism between warfarin and DOACs in patients receiving endoscopic treatment. In terms of delayed bleeding, discontinuous warfarin without HBT was suggested as the best management, and dabigatran was recommended as the best type of DOAC.
Collapse
Affiliation(s)
- Xianhong Zhao
- Department of Gastroenterology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China
| | - Yangxue Huang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong, China
| | - Jiarong Li
- Department of Gastroenterology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China
| | - Aoqiang Zhou
- Centre for Translational Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China
| | - Gengxin Chen
- Centre for Translational Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China
| | - Haixia Deng
- Department of Gastroenterology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China
| |
Collapse
|
6
|
Liu YO, Wang ZN, Chen CY, Zhuang XH, Ruan CG, Zhou Y, Cui YM. Antiplatelet Effect of a Pulaimab [Anti-GPIIb/IIIa F(ab)2 Injection] Evaluated by a Population Pharmacokinetic-pharmacodynamic Model. Curr Drug Metab 2019; 20:1060-1072. [PMID: 31755383 DOI: 10.2174/1389200220666191122120238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/01/2019] [Accepted: 10/25/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiovascular disease has one of the highest mortality rates among all the diseases. Platelets play an important role in the pathogenesis of cardiovascular diseases. Platelet membrane glycoprotein GPIIb/IIIa antagonists are the most effective antiplatelet drugs, and pulaimab is one of these. The study aims to promote individual medication of pulaimab [anti-GPIIb/IIIa F(ab)2 injection] by discovering the pharmacological relationship among the dose, concentration, and effects. The goal of this study is to establish a population pharmacokineticpharmacodynamic model to evaluate the antiplatelet effect of intravenous pulaimab injection. METHODS Data were collected from 59 healthy subjects who participated in a Phase-I clinical trial. Plasma concentration was used as the pharmacokinetic index, and platelet aggregation inhibition rate was used as the pharmacodynamic index. The basic pharmacokinetics model was a two-compartment model, whereas the basic pharmacodynamics model was a sigmoid-EMAX model with a direct effect. The covariable model was established by a stepwise method. The final model was verified by a goodness-of-fit method, and predictive performance was assessed by a Bootstrap (BS) method. RESULTS In the final model, typical population values of the parameters were as follows: central distribution Volume (V1), 183 L; peripheral distribution Volume (V2), 349 L; Central Clearance (CL), 31 L/h; peripheral clearance(Q), 204 L/h; effect compartment concentration reaching half of the maximum effect (EC50), 0.252 mg/L; maximum effect value (EMAX), 54.0%; and shape factor (γ), 0.42. In the covariable model, thrombin time had significant effects on CL and EMAX. Verification by the goodness-of-fit and BS methods showed that the final model was stable and reliable. CONCLUSION A model was successfully established to evaluate the antiplatelet effect of intravenous pulaimab injection that could provide support for the clinical therapeutic regimen.
Collapse
Affiliation(s)
- Ya-Ou Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zi-Ning Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Chao-Yang Chen
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xian-Han Zhuang
- Shanghai Asia United Antibody Medicine Limited Company, Shanghai, China
| | - Chang-Geng Ruan
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Suzhou University, Suzhou, Jiangsu, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| |
Collapse
|
7
|
Nagata N, Yasunaga H, Matsui H, Fushimi K, Watanabe K, Akiyama J, Uemura N, Niikura R. Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis. Gut 2018; 67:1805-1812. [PMID: 28874418 PMCID: PMC6145295 DOI: 10.1136/gutjnl-2017-313999] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/19/2017] [Accepted: 07/30/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the risks of postendoscopy outcomes associated with warfarin with direct oral anticoagulants (DOACs), taking into account heparin bridging and various types of endoscopic procedures. DESIGN Using the Japanese Diagnosis Procedure Combination database, we identified 16 977 patients who underwent 13 types of high-risk endoscopic procedures and took preoperative warfarin or DOACs from 2014 to 2015. One-to-one propensity score matching was performed to compare postendoscopy GI bleeding and thromboembolism between the warfarin and DOAC groups. RESULTS In the propensity score-matched analysis involving 5046 pairs, the warfarin group had a significantly higher proportion of GI bleeding than the DOAC group (12.0% vs 9.9%; p=0.002). No significant difference was observed in thromboembolism (5.4% vs 4.7%) or in-hospital mortality (5.4% vs 4.7%). The risks of GI bleeding and thromboembolism were greater in patients treated with warfarin plus heparin bridging or DOACs plus bridging than in patients treated with DOACs alone. Compared with percutaneous endoscopic gastrostomy, patients who underwent endoscopic submucosal dissection, endoscopic mucosal resection and haemostatic procedures including endoscopic variceal ligation or endoscopic injection sclerotherapy were at the highest risk of GI bleeding among the 13 types of endoscopic procedures, whereas those who underwent lower polypectomy endoscopic sphincterotomy or endoscopic ultrasound-guided fine needle aspiration were at moderate risk. CONCLUSION The risk of postendoscopy GI bleeding was higher in warfarin than DOAC users. Heparin bridging was associated with an increased risk of bleeding and did not prevent thromboembolism. The bleeding risk varied by the type of endoscopic procedure.
Collapse
Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
8
|
Mizuki A, Tatemichi M, Nagata H. Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed! Inflamm Intest Dis 2018; 3:100-106. [PMID: 30733954 DOI: 10.1159/000490387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background/Summary Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is "preferable." Key Messages This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.
Collapse
Affiliation(s)
- Akira Mizuki
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
| | - Masayuki Tatemichi
- Department of Community Health, Tokai University School of Medicine, Isehara, Japan
| | - Hiroshi Nagata
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
| |
Collapse
|
9
|
Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
Collapse
Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
| |
Collapse
|
10
|
Arepalli S, Sears JE, Srivastava SK, Deasy R, Singh RP, Ehlers JP, Kaiser PK, Martin D, Sharma S, Yuan A, Schachat AP, Rachitskaya AV. Pre–Retinal Surgery Identification of Novel Anticoagulation and Antiplatelet Agents. ACTA ACUST UNITED AC 2018; 2:254-255. [DOI: 10.1016/j.oret.2017.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/16/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022]
|
11
|
Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017; 130:786-795. [PMID: 28344132 DOI: 10.1016/j.amjmed.2017.01.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/14/2023]
Abstract
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
Collapse
Affiliation(s)
- Linda Anne Feagins
- Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
| |
Collapse
|
12
|
Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
Collapse
Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
| |
Collapse
|
13
|
Atwell TD, Wennberg PW, McMenomy BP, Murthy NS, Anderson JR, Kriegshauser JS, McKinney JM. Peri-procedural use of anticoagulants in radiology: an evidence-based review. Abdom Radiol (NY) 2017; 42:1556-1565. [PMID: 28070656 DOI: 10.1007/s00261-016-1027-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.
Collapse
|
14
|
Lange CM, Fichtlscherer S, Miesbach W, Zeuzem S, Albert J. The Periprocedural Management of Anticoagulation and Platelet Aggregation Inhibitors in Endoscopic Interventions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:129-35. [PMID: 26976713 DOI: 10.3238/arztebl.2016.0129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND In Germany, more than half a million persons, most of them elderly, are under long-term treatment with anticoagulants. The approval of new oral anticoagulants and platelet aggregation inhibitors, as well as new data on periprocedural bridging with heparins, have introduced marked complexity to the management of treatment with anticoagulants and platelet aggregation inhibitors for endoscopic interventions in visceral surgery. METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed, as well as on the relevant guidelines. RESULTS Robust data are available on the management of vitamin K antagonists (VKA) and platelet aggregation inhibitors for endoscopic procedures; on the other hand, the data on the periprocedural management of non-VKA oral anticoagulants (NOAC) are still inadequate. Endoscopic procedures that carry a low risk of bleeding can be performed under treatment with anticoagulants or platelet aggregation inhibitors. Before any procedure with a high risk of bleeding (≥ 1.5%) oral anticoagulants of any type and P2Y12 inhibitors should generally be discontinued. Patients in whom VKA are temporarily discontinued for this reason need bridging treatment with heparin only if they are at high risk of thromboembolic events (≥ 10% per year). For patients who are anticoagulated with NOAC, timely discontinuation of the drug depending on renal function is of key importance, and bridging is usually unnecessary. CONCLUSION Adequate scientific evidence supports the current recommendations and treatment algorithms for the periprocedural management of oral anticoagulants and platelet aggregation inhibitors in endoscopic procedures. Larger-scale studies are still needed to provide a sound basis for the corresponding recommendations about NOAC.
Collapse
Affiliation(s)
- Christian M Lange
- Gastroenterology and Hepatology, Department of Medicine 1, Frankfurt University Hospital, Frankfurt am Main, Cardiology, Department of Medicine 3, Frankfurt University Hospital, Frankfurt am Main, Hemostaseology, Department of Medicine 2, Frankfurt University Hospital, Frankfurt am Main
| | | | | | | | | |
Collapse
|
15
|
Plumé Gimeno G, Bustamante-Balén M, Satorres Paniagua C, Díaz Jaime FC, Cejalvo Andújar MJ. Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:49-59. [PMID: 27809553 DOI: 10.17235/reed.2016.4114/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.
Collapse
|
16
|
Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy. Best Pract Res Clin Gastroenterol 2016; 30:705-718. [PMID: 27931631 DOI: 10.1016/j.bpg.2016.09.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/27/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.
Collapse
|
17
|
.Lange CM, Albert J. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:541-542. [PMID: 27581511 PMCID: PMC5012168 DOI: 10.3238/arztebl.2016.0541c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Jörg Albert
- *Goethe Universitätsklinikum Frankfurt am Main,
| |
Collapse
|
18
|
Luo H, Zhao L, Leung J, Zhang R, Liu Z, Wang X, Wang B, Nie Z, Lei T, Li X, Zhou W, Zhang L, Wang Q, Li M, Zhou Y, Liu Q, Sun H, Wang Z, Liang S, Guo X, Tao Q, Wu K, Pan Y, Guo X, Fan D. Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet 2016; 387:2293-2301. [PMID: 27133971 DOI: 10.1016/s0140-6736(16)30310-5] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rectal indometacin decreases the occurrence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the population most at risk and the optimal timing of administration require further investigation. We aimed to assess whether pre-procedural administration of rectal indometacin in all patients is more effective than post-procedural use in only high-risk patients to prevent post-ERCP pancreatitis. METHODS We did a multicentre, single-blinded, randomised controlled trial at six centres in China. Eligible patients with native papilla undergoing ERCP were randomly assigned in a 1:1 ratio (with a computer-generated list) to universal pre-procedural indometacin or post-procedural indometacin in only high-risk patients, with stratification by trial centres and block size of ten. In the universal indometacin group, all patients received a single dose (100 mg) of rectal indometacin within 30 min before ERCP. In the risk-stratified, post-procedural indometacin group, only patients at predicted high risk received rectal indometacin, immediately after ERCP. Investigators, but not patients, were masked to group allocation. The primary outcome was overall ocurrence of post-ERCP pancreatitis. The analysis followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT02002650. FINDINGS Between Dec 15, 2013, and Sept 21, 2015, 2600 patients were randomly assigned to universal, pre-procedural indometacin (n=1297) or risk-stratified, post-procedural indometacin (n=1303). Overall, post-ERCP pancreatitis occurred in 47 (4%) of 1297 patients assigned to universal indometacin and 100 (8%) of 1303 patients assigned to risk-stratified indometacin (relative risk 0·47; 95% CI 0·34-0·66; p<0·0001). Post-ERCP pancreatitis occurred in 18 (6%) of 305 high-risk patients in the universal group and 35 (12%) of 281 high-risk patients in the risk-stratified group (p=0·0057). Post-ERCP pancreatitis was also less frequent in average-risk patients in the universal group (3% [29/992]), in which they received indometacin, than in the risk-stratified group (6% [65/1022]), in which they did not receive the drug (p=0·0003). Other than pancreatitis, adverse events occurred in 41 (3%; two severe) patients in the universal indometacin group and 48 (4%; one severe) patients in the risk-stratified group. The most common adverse events were biliary infection (22 [2%] patients vs 33 [3%] patients) and gastrointestinal bleeding (13 [1%] vs ten [1%]). INTERPRETATION Compared with a risk-stratified, post-procedural strategy, pre-procedural administration of rectal indometacin in unselected patients reduced the overall occurrence of post-ERCP pancreatitis without increasing risk of bleeding. Our results favour the routine use of rectal indometacin in patients without contraindications before ERCP. FUNDING National Key Technology R&D Program, National Natural Science Foundation of China.
Collapse
Affiliation(s)
- Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Lina Zhao
- Department of Radiotherapy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Joseph Leung
- Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, and UC Davis Medical Center, Sacramento, CA, USA
| | - Rongchun Zhang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiangping Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanguo Nie
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Ting Lei
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Xun Li
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Wence Zhou
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lingen Zhang
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ming Li
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yi Zhou
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Qian Liu
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Hao Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuhui Liang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaoyang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qin Tao
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | - Xuegang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| |
Collapse
|
19
|
Saito MS, Lourenço AL, Kang HC, Rodrigues CR, Cabral LM, Castro HC, Satlher PC. New approaches in tail-bleeding assay in mice: improving an important method for designing new anti-thrombotic agents. Int J Exp Pathol 2016; 97:285-92. [PMID: 27377432 PMCID: PMC4960579 DOI: 10.1111/iep.12182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 03/10/2016] [Indexed: 12/11/2022] Open
Abstract
This report describes a modified, simple, low-cost and more sensitive method to determine bleeding patterns and haemoglobin concentration in a tail-bleeding assay using BALB/c mice and tail tip amputation. The cut tail was immersed in Drabkin's reagent to promote erythrocyte lysis and haemoglobin release, which was monitored over 30 min. The operator was blinded to individual conditions of the mice, which were treated with either saline (NaCl 0.15m), DMSO (0.5%) or clinical anti-thrombotic drugs. Our experimental protocols showed good reproducibility and repeatability of results when using Drabkin's reagent than water. Thus, the use of Drabkin's reagent offered a simple and low-cost method to observe and quantify the bleeding and rebleeding episodes. We also observed the bleeding pattern and total haemoglobin loss using untreated animals or those under anti-coagulant therapy in order to validate the new Drabkin method and thus confirm that it is a useful protocol to quantify haemoglobin concentrations in tail-bleeding assay. This modified method provided a more accurate results for bleeding patterns in mice and for identifying new anti-thrombotic drugs.
Collapse
Affiliation(s)
- Max Seidy Saito
- Laboratório de Antibióticos Bioquímica Ensino e Modelagem Molecular (LABiEMol) - Instituto de Biologia, Universidade Federal Fluminense, Niterói, RJ, Brazil
- Programa de Pós-Graduação em Patologia (PPG-UFF) - Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - André Luiz Lourenço
- Laboratório de Antibióticos Bioquímica Ensino e Modelagem Molecular (LABiEMol) - Instituto de Biologia, Universidade Federal Fluminense, Niterói, RJ, Brazil
- Programa de Pós-Graduação em Patologia (PPG-UFF) - Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Hye Chung Kang
- Programa de Pós-Graduação em Patologia (PPG-UFF) - Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Carlos Rangel Rodrigues
- Laboratório de Modelagem Molecular e QSAR (ModMolQSAR) - Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucio Mendes Cabral
- Laboratório de Tecnologia Industrial Farmacêutica (LabTIF) - Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Helena Carla Castro
- Laboratório de Antibióticos Bioquímica Ensino e Modelagem Molecular (LABiEMol) - Instituto de Biologia, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Plínio Cunha Satlher
- Laboratório de Antibióticos Bioquímica Ensino e Modelagem Molecular (LABiEMol) - Instituto de Biologia, Universidade Federal Fluminense, Niterói, RJ, Brazil
- Laboratório de Tecnologia Industrial Farmacêutica (LabTIF) - Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
20
|
ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
Collapse
|
21
|
González Bárcenas ML, Pérez Aisa Á. Management of antiplatelet and anticoagulant therapy for endoscopic procedures: Introduction to novel oral anticoagulants. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:89-96. [PMID: 26838491 DOI: 10.17235/reed.2016.3811/2015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The development of novel antithrombotic therapy in the past few years and its prescription in patients with cardiovascular and circulatory disease has widened the spectrum of drugs that need to be considered when performing an endoscopic procedure. The balance between the thrombotic risk patients carry due to their medical history and the bleeding risk involved in endoscopic procedures should be thoroughly analyzed by Gastroenterologists. New oral anticoagulants (NOACs) impose an additional task. These agents, that specifically target factor IIa or Xa, do not dispose of an anticoagulation monitoring method nor have an antidote to revert their effect, just as with antiplatelet agents. Understanding the fundamental aspects of these drugs provides the necessary knowledge to determine the ideal period the antithrombotic therapy should be interrupted in order to perform the endoscopic procedure, offering maximum safety for patients and optimal results.
Collapse
|
22
|
Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives. Thromb Res 2015; 136:1074-81. [PMID: 26508464 DOI: 10.1016/j.thromres.2015.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. The rate of major GIB related to the use of some direct acting oral anticoagulant drugs (DOACs), is higher than that detected in warfarin users. Current strategies in the treatment of GIBs in patients receiving warfarin or DOACs (vitamin K, activated charcoal; hemodialysis; recombinant factor VIIa; [activated] prothrombin complex concentrates) including indications for the treatment of bleeding based on different degrees of severity of the episodes, is reported in this article. Potential preventive strategies to mitigate the risk of GIBs (e.g. upper endoscopy/biopsy, colon cancer screening; eradication of Helicobacter pylori prior to starting anticoagulation; use of proton-pump inhibitors, identification of risk factors for bleeding) are also reported as well as the fact that some of them have not been tested so far in patients receiving DOACs. Antidotes that experimentally reverse the anti-coagulant effect of dabigatran (Idarucizumab; BI 655075; Boehringer Ingelheim); of rivaroxaban, apixaban, or edoxaban (Andexanet alfa, r-Antidote, PRT064445; Portola Pharmaceuticals) or of all DOACs (Aripazine, PER-977, ciraparantag; Perosphere Inc.) are discussed. Likewise, population pharmacokinetics modeling related to the rate of major DOACs-related GIBs is presented. It is also emphasized that the occurrence of GIB reflects the presence of patients at the highest risk for adverse outcomes. Finally, the implications of the concept that patient characteristics and the severity of illness (i.e. comorbidities) exert a greater impact on the risk of GIB than the type of antithrombotic agent employed, are analyzed.
Collapse
|
23
|
Management of Anticoagulant and Antiplatelet Medications in Adults Undergoing Percutaneous Interventions. AJR Am J Roentgenol 2015. [PMID: 26204296 DOI: 10.2214/ajr.14.13342] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Many radiologists are unfamiliar with the new antithrombogenic medications and how to modify patient management before nonvascular percutaneous procedures performed in a radiology department. In this article, we review the indications for use, mechanism of action, pharmacokinetics, dosing, and recommendations for periprocedural management of patients using these medications. CONCLUSION To improve patient safety, radiologists involved in percutaneous procedures should have knowledge of the antithrombotics that will be encountered routinely in clinical practice.
Collapse
|
24
|
Manejo de antitrombóticos en pacientes que requieren procedimientos endoscópicos. ENDOSCOPIA 2015. [DOI: 10.1016/j.endomx.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
25
|
Radaelli F, Dentali F, Repici A, Amato A, Paggi S, Rondonotti E, Dumonceau JM. Management of anticoagulation in patients with acute gastrointestinal bleeding. Dig Liver Dis 2015; 47:621-7. [PMID: 25935464 DOI: 10.1016/j.dld.2015.03.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/31/2015] [Indexed: 12/11/2022]
Abstract
Acute gastrointestinal bleeding represents the most common adverse event associated with the use of oral anticoagulant therapy. Due to increasing prescription of anticoagulants worldwide, gastroenterologists are more and more called to deal with bleeding patients taking these medications. Their management is challenging because several issues have to be taken into account, such as the severity of bleeding, the intensity of anticoagulation, the patient's thrombotic risk and endoscopy findings. The recent introduction into the marketplace of new direct oral anticoagulants, for whom specific reversal agents are still lacking, further contributes to make the decision-making process even more demanding. Available evidence on this topic is limited and practice guidelines by gastroenterology societies only marginally address key issues for clinicians, including when and how to reverse coagulopathy, the optimal timing of endoscopy and when and how to resume anticoagulation thereafter. The present paper reviews the evidence in the literature and provides practical algorithms to support clinicians in the management of patients on anticoagulants who present with acute gastrointestinal bleeding.
Collapse
Affiliation(s)
- Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy.
| | - Francesco Dentali
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - Alessandro Repici
- Gastrointestinal Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Arnaldo Amato
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Silvia Paggi
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | | | | |
Collapse
|
26
|
Abstract
Most colorectal cancer arises from adenomatous polyps. This gradual process may be interrupted by screening and treatment using colonoscopy and polypectomy. Advances in imaging platforms have led to classification systems that facilitate prediction of histologic type and both stratification for and prediction of the risk of invasion. Endoscopic treatment should be the standard of care even for extensive advanced mucosal neoplasm. Technique selection is influenced by lesion features, location, patient factors, and local expertise. Postprocedural complications are more common following advanced resection and endoscopists should be familiar with risk factors, early detection methods, and management.
Collapse
Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Crn Hawkesbury & Darcy Rds, Sydney, Westmead New South Wales 2145, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Crn Hawkesbury & Darcy Rds, Sydney, Westmead New South Wales 2145, Australia.
| |
Collapse
|
27
|
Chavalitdhamrong D, Adler DG, Draganov PV. Complications of enteroscopy: how to avoid them and manage them when they arise. Gastrointest Endosc Clin N Am 2015; 25:83-95. [PMID: 25442960 DOI: 10.1016/j.giec.2014.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Deep small bowel enteroscopy is a safe procedure that has revolutionized the strategy for diagnosis and treatment of small bowel diseases. However, enteroscopy-associated adverse events are more common compared with standard endoscopy. Prevention, early detection, and effective intervention are crucial in reducing the adverse event severity and improving outcomes. In this article, how to safely perform enteroscopy, avoid adverse events, detect adverse events early, and accomplish effective treatments are discussed. This knowledge can serve as a continuing quality improvement process to reduce the risk of future adverse events and improve the overall quality of endoscopy.
Collapse
Affiliation(s)
- Disaya Chavalitdhamrong
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, 30 North 1900 East 4R 118, Salt Lake City, UT 84132, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
28
|
Sugano K. How do we manage serious gastrointestinal adverse events associated with anti-thrombotic therapy? Expert Rev Gastroenterol Hepatol 2015; 9:5-8. [PMID: 25096360 DOI: 10.1586/17474124.2014.945913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Antithrombotic therapy (ATTs) is increasingly used worldwide for preventing primary or recurrent thrombotic events. Moreover, newer oral anti-platelet drugs and anti-coagulants have been introduced for clinical use, accelerating the number of patients under ATT. Not infrequently, these drugs are used in combination. These drugs, however, are well-known for adverse events in which gastrointestinal bleeding (GIB) is most common. Bleeding during ATT can be fatal, but even when patients survive, their prognosis is rather poor. Therefore, it is imperative to minimize such events. So far, co-prescription of proton pump inhibitor (PPI) has been documented to be the most effective in reducing upper GI injury and bleeding, though deliberate use of PPIs is required to minimize drug interaction and associated adverse events with acid suppression. In addition, we should note that PPI is not effective in preventing mid- or lower-GI injury/bleeding for which only limited evidence on preventive measures is available.
Collapse
Affiliation(s)
- Kentaro Sugano
- Department of Medicine, Jichi Medical University, 3311-1 Shimotsuke, Tochigi 329-0498, Japan
| |
Collapse
|