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  • Morbidity Conference Presentation : R1 黃景燦
  • Patient Profile
    • Name : 吳 O 和
    • Gender : Male
    • Age : 61
    • Medical History :
      • Hypertension, regular followed up at 署南醫院
      • Anti-platelet use ?
    • Personal History :
      • Smoking: about 1.5 PPD for 20 years, quitted for 1 year
      • Alcohol: sometimes
  • 美兆健檢中心 elevated CEA = 7.5 98-09-01 GI OPD 98-09-02 Abdominal fullness Not icteric or anemic PE : negative Colonoscopy 98-09-15 Colon polyps s/p biopsy Rectal polyp s/p biopsy and total removal Mild internal hemorrhoids Colonoscopy Patho : tubular adenoma
  • Colonoscopy on 980915 1 2 3 4
  • Colonoscopy on 980915 1 2 3 4
  • Colonoscopy on 980915 1 2 3 4
  • Colonoscopy on 980915 1 2 3 4
  • Colonoscopy on 980915 1 2 3 4
  • Colonoscopy on 980915
  • ER 98-09-16 GI ward 98-09-17 Bloody stool for 5 times mild dizziness Anemia (Hb 11.9g/dl) Hypokalemia (K 2.98mEq/L) Hb = 10.9 g/dL GI ward 98-09-18 Hb = 11.0 g/dL Transamin infusion No bloody stool passage Other lab datas
  • Lab Data
    • WBC : 4700/uL, S/L/M : 64.9/21.1/7.3%
    • Hb : 11.9g/dL , MCV : 92.7fL
    • Platelet : 185000/uL
    • Na/K : 142.6 / 2.98 mEq/L
    • BUN/Creatinine : 18/1.09 mg/dL
    • PT/aPTT : INR 0.9,
    • PT 10.2”/10.0”, aPTT 29.7”/29.6”
  • 98-09-20 Discharge 98-09-22 Hb = 8.9 g/dL GI ward Hb = 7.0 g/dL 98-09-21 Ascending colon polyp s/p polypectomy Internal hemorrhoids Colonoscopy No bloody stool PRBC 2U transfusion
  • Colonoscopy on 980921 1 2 3 4
  • Colonoscopy on 980921 1 2 3 4
  • Colonoscopy on 980921 1 2 3 4
  • Colonoscopy on 980921 1 2 3 4
  • Colonoscopy on 980921 1 2 3 4
  • Colonoscopy on 980921
  • Discussion
    • Gastroenterologic procedures in patients with disorders of hemostasis, uptodate
    • Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
    • Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329 .
  • INTRODUCTION
    • Anticoagulation therapy with warfarin is used to reduce the risk of thromboembolic events in patients with certain cardiovascular conditions, deep vein thrombosis (DVT), and hypercoagulable states.
    • Anticoagulation therapy complicates the management of gastrointestinal bleeding. Interruption of anticoagulation therapy may be desirable for some patients undergoing endoscopic procedures.
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • REVERSING ANTICOAGULATION IN ACUTE HEMORRHAGE
    • FFP or Vit. K?
    • Fresh frozen plasma can be used to correct a supratherapeutic international normalized ratio (INR).
    • In one report, successful hemostasis was achieved with endoscopic therapy in 91 percent of 52 patients with acute upper gastrointestinal bleeding after correcting the INR to 1.5 to 2.5, a success rate comparable to a control population of patients who were not anticoagulated.
    • In contrast, vitamin K is less useful in the acute setting because of its delayed onset of action (12 to 24 hours) and the prolonged time required to reestablish therapeutic anticoagulation after its use .
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • ELECTIVE PROCEDURES IN ANTICOAGULATED PATIENTS   
    • Procedure risks
    • Bleeding rate :
    • colonoscopic polypectomy (1%-2.5%),
    • gastric polypectomy (4%), laser ablation and coagulation (less than 6%),
    • endoscopic sphincterotomy (2.5%-5%)
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • ELECTIVE PROCEDURES IN ANTICOAGULATED PATIENTS   
    • Condition risks
    • Mechanical valves with thromboembolic events–
    • Absence of therapy – 4 per 100 patient-years
    • Antiplatelet – 2.2 per 100 patient-years
    • Warfarin – 1 per 100 patient-years
    • Target INR – 3.0 ~ 4.0
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • ELECTIVE PROCEDURES IN ANTICOAGULATED PATIENTS   
    • Condition risks
    • Atrial fibrillation –
    • unassociated with valvular disease : 5% ~ 7% annually
    • concomitant dilated cardiomyopathy, valvular heart disease, or recent thromboembolic events, the risk is greater.
    • Target INR : 3.0
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • ELECTIVE PROCEDURES IN ANTICOAGULATED PATIENTS   
    • Condition risks
    • Deep Vein Thrombosis –
    • Anticoagulation therapy for DVT is typically carried out for 1 to 6 months.
    • Early cessation of anticoagulation therapy for short time periods does not appear to increase significantly the risk of pulmonary embolus.
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • ELECTIVE PROCEDURES IN ANTICOAGULATED PATIENTS   
    • The absolute risk of an embolic event (major, minor, valve thrombosis) for patients with a low risk condition in whom anticoagulation is interrupted for 4 to 7 days may be estimated at 1 to 2 per 1000 patients .
    • When anticoagulation therapy is temporary, such as for DVT, elective procedures should be delayed, if possible, until anticoagulation is no longer indicated.
    • The administration of vitamin K to reverse anticoagulation for elective procedures should be avoided because it delays therapeutic anticoagulation once anticoagulants are resumed.
    Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, VOLUME 55,NO.7,2002 GASTROINTESTINAL ENDOSCOPY
  • Summary of recommendations
    • Gastroenterologic procedures in patients with disorders of hemostasis, uptodate
    • Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329 .
  • Acute gastro-intestinal haemorrhage
    • The immediate risk to the patient from haemorrhage may outweigh the risk of thrombosis as a result of stopping anticoagulant or antiplatelet therapy.
    • Patients need to be assessed on an individual basis, and it is not possible to give unequivocal guidance to cover all situations.
    • Clopidogrel should not be discontinued without discussion with a cardiologist . If clopidogrel therapy needs to be discontinued in this context, then this should be limited to a maximum of 5 days as the risk of stent thrombosis increases after this interval.
  • ASPIRIN, NSAIDS AND OTHER ANTIPLATELET DRUGS  
    • The ASGE recognizes that aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) given in standard doses do not increase the risk of significant bleeding after upper endoscopy with biopsy, colonoscopy with biopsy, polypectomy, or biliary sphincterotomy
  • Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329.
  • Low-risk endoscopic procedures Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329.
  • High-risk endoscopic procedure Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329.
  • Take home message
    • Reversing anticoagulation in acute hemorrhage,
    • FFP is greater than Vit. K .
    • Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) given in standard doses do not increase the risk of significant bleeding
    • Warfarin in high-risk procedure :
      • stop warfarin 5 days before endoscopy and add back at the evening of the procedure
      • high risk : add LMWH 2 days after procedure and DC until adequate INR.
    • Clopidogrel in high-risk procedure :
      • Stop 7 days before endoscopy, add or continue aspirin use .
      • Restart on the day following the procedure
  • Thanks for your attention~!
  • Yamada’s classification
    • Yamada’s classification.
      • Type I polyps are elevated, with an indistinct border
      • Type II polyps are elevated with a distinct border at the base but no notch.
      • Type III polyps are elevated, but no peduncle
      • Type IV polyps are pedunculated and elevated
  •