Colonoscopic polypectomy in anticoagulated patients

AIM： To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation. METHODS： Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically. RESULTS： One patient （0.8%, 95% CI： 0.1%-4.5%） developed major post-polypectomy bleeding that required transfusion. Two others （1.6%, 95% CI： 0.5%-5.7%） had self-limited hematochezia at home and did not seek medical attention. The average polyp size was 5.1±2.2 mm. CONCLUSION： Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.     

Colonoscopy surveillance after polypectomy

The goal of surveillance examinations after polypectomy is to detect new adenomas and missed synchronous adenomas, as well as preventing adenomas from becoming invasive or cancerous. The first colonoscopy surveillance program reported was the National Polyp Study from the United States in 1997, with an update in 2003. First screening colonoscopy and polypectomy have been shown to produce the greatest effects in reducing the incidence of colorectal cancer in patients with adenomatous polyps. However, a large number of adenomas are being discovered as a result of the increased use of colorectal cancer screening, particularly with the dramatic increase in screening colonoscopy and surveillance. Increased efficiency of surveillance colonoscopy practices is therefore needed to decrease the cost, risk, and overuse of medical resources. In developing surveillance programs, studying miss rates and incidences and performing separate evaluations are important, along with accurately assessing incidence. This is because the recurrence rate or apparent incidence after colonoscopic polypectomy includes the true incidence of new polyp formation plus the incidence of missed polyps from the initial colonoscopy. Many studies have indicated the number of adenomas on initial examination as the most significant predictor for missed adenoma and incidence of adenoma on surveillance colonoscopy. In Japan, many facets of colonoscopic examination differ from those in Western countries. Further studies are recommended to establish an appropriate and original Japanese colonoscopy surveillance program for use after polypectomy, based on guidelines from the United States.     

Colonoscopy in patients with benign anorectal disease

A prospective study was performed to determine the incidence of colorectal neoplasia and inflammatory bowel disease in patients with benign anorectal disease. Over a three-year period, 102 consecutive patients who presented with hemorrhoids, fissure, fistula-in-ano, anorectal abscess, and anal condylomata and who did not have gastrointestinal symptoms underwent colonoscopy. The mean age of all patients was 535 years; males outnumbered females 1.61. No patient was found to have inflammatory bowel disease. Ten of 102 (9.8 percent) were found to have a neoplastic lesion (nine adenomas and one adenocarcinoma). Patients found to have a neoplastic lesion tended to be older (61 years vs.52.7 years; P =0.06). Neoplasia was found in 4 of 21 (19 percent) with a family history of colorectal cancer and in 6 of 81 (7.4 percent) without a family history (P =0.24). Patients presenting with outlet-type bleeding were not found to have a higher detection of neoplasia. The specific type of anorectal disease present was not associated with an increased risk for colorectal neoplasia. Our study suggests that benign anorectal disease and colorectal neoplasia may coexist. Anorectal disease is not predictive of neoplasia. The decision to perform colonoscopy should be based on age, gastrointestinal symptoms, and other risk factors.     

Colonoscopy in ostomy patients

Patients with a personal history of rectal cancer are considered at high risk for metachronous large-bowel primaries. Since a malignant growth was the main reason for performing a colostomy in patients followed at the centers of the authors' association (AISTOM), a correct follow-up approach for these patients is very important. A multicentric clinical trial was thus carried out to evaluate the efficacy of transstomal endoscopic exploration (TEE) of the residual colon, and data collection began on May 31, 1984. Nine hundred fifty-seven patients were submitted to TEE after curative abdominoperineal resection (Miles) for rectal cancer. The male-female ratio was 1.3; 89.6 percent of the patients were over 50 years of age. A family history of large-bowel cancer was present in 18 percent, and in 23 percent of the patients the cancer was associated with synchronous adenomas. Only 31 percent of the patients had colonoscopy or double-contrast barium enema x-ray beyond the neoplastic area before surgery. TEE was done in 96.8 percent of the patients; in 3.3 percent the examination was not possible, mainly for stenosis of the stoma (in 2.3 percent). In 82 percent of the patients a complete large-bowel exploration was possible: a new large, bowel cancer was found in 22 patients (2.2 percent) and an adenoma in 183 patients (19.1 percent). These results show that, because it is safe, practical, and effective, endoscopy plays an important role in the follow-up of ostomates.     

Cerebral haemorrhage in anticoagulated patients with non-septic mechanical valvular prosthesis

Cerebral haemorrhage in anticoagulated patients with mechanical valvular prosthesis poses an uncommon but difficult management problem. Four such patients are presented: one patient had delayed haemorrhagic transformation of a preexisting cerebral infarct, one probably had de novo haemorrhage complicating hypertension and in two patients cerebral haemorrhage was associated with excessive anticoagulation. Conservative management including the use of fresh frozen plasma, delayed heparinisation and warfarinisation was used. Both patients with anticoagulant overdose died as a result of extensive haemorrhage despite the drainage of cerebellar haematoma in one patient. The remaining two patients survived with minimal neurological deficits. Diagnosis of the underlying cause of cerebral haemorrhage, and the timing of heparinisation and anticoagulation are discussed.     

Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation

Aims. To test the hypothesis that stroke and systemic embolic events (SEE) in the stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) III and V trials are different between paroxysmal and persistent atrial fibrillation (AF). Methods. Data analysis from two cohorts of patients enroled in the prospective SPORTIF III and V clinical trials (n = 7329); 836 subjects (11.4%) with paroxysmal AF [mean age 70.1 years (SD = 9.5)] were compared with 6493 subjects with persistent AF for this ancillary study. Results. The annual event rates for stroke/SEE are 1.73% for persistent AF and 0.93% for paroxysmal AF. In a multivariate analysis, after adjusting for stroke risk factors, gender and aspirin usage, the differences remained statistically significant with a higher hazard ratio (HR) for stroke/SEE in persistent AF [vs. paroxysmal AF, HR 1.87, 95% confidence interval (CI) 1.04–3.36; P = 0.037]. In ‘high risk’ patients (with ≥2 stroke risk factors) annual event rates for stroke/SEE were 2.08% for persistent AF and 1.27% for paroxysmal AF (adjusted HR = 1.68, 95% CI 0.91–3.1, P = 0.098). Elderly patients had annual event rates for stroke/SEE of 2.38% for persistent AF and 1.13% for paroxysmal AF (adjusted HR = 2.27, 95% CI 0.92–5.59, P = 0.075). Vitamin K antagonist (VKA)‐naïve paroxysmal AF patients had a 1.89%/year stroke/SEE rate, compared with 0.61% for previous VKA takers (HR = 0.33, 95% CI 0.11–1.01, P = 0.052). Conclusion. In this large clinical trial cohort of anticoagulated AF patients, those with paroxysmal AF had stroke rates which were lower than for patients with persistent AF, although both groups had broadly similar stroke risk factors. Subjects with paroxysmal AF at ‘high risk’ had stroke/SEE rates that were not significantly different to persistent AF subjects.     

Occult pulmonary hemorrhage in anticoagulated patients.

Evidence for severe intrapulmonary bleeding was obtained in 3 anticoagulated patients who presented with pulmonary infiltrates. The diagnosis of pulmonary hemorrhage was based on findings of markedly elevated quantities of stainable hemosiderin and hemoglobin in alveolar macrophages retrieved by bronchopulmonary lavage. In 2 of the patients, roentgenographic abnormalities regressed after anticoagulation was reversed. The third patient died and massive bilateral pulmonary hemorrhage was found at autopsy. The syndrome of occult pulmonary hemorrhage was characterized clinically by dyspnea, unexplained acute anemia, and infiltrates with an alveolar pattern on chest roentgenogram. Hemoptysis was conspicuously absent. Bronchopulmonary lavage and quantification of alveolar macrophage hemosiderin content may be useful in identifying intrapulmonary bleeding occurring in an otherwise occult manner. Recognition of pulmonary hemorrage in anticoagulated patients is important because reversal of anticoagulation can be life saving.     

Unsuspected hyperhomocysteinemia in chronically anticoagulated patients.

Hyperhomocysteinemia is a risk factor for arterial and venous thrombosis. The aim of this study was to evaluate plasmatic homocysteine levels in patients under chronic anticoagulant treatment with dietary restriction of green vegetables. This kind of food is a very important source not only of vitamin K but also of folates, which are involved in Hcy metabolism. It is known that the lower the folate levels, the higher the Hcy concentration, so we suspected that these patients could show hyperhomocysteinemia. A group of patients receiving oral anticoagulant treatment and a restricted diet (Group I, n = 20) was compared with a group of untreated subjects of a similar age that were not on a restricted diet (Group II, n = 35). Group I showed significantly higher levels of plasmatic Hcy and significantly lower levels of serum folate than Group II. Therefore, a diet restricted in vitamin K applied to oral anticoagulated patients could induce an unwanted increase of homocysteine levels.     

Surveillance strategies in patients after polypectomy

Colorectal cancer (CRC) is a major cause of cancer death in the Western world. It develops slowly over several years from premalignant lesions (most prominently adenomatous polyps) to invasive cancer. The molecular basis of CRC pathogenesis has been well characterized. The most effective method to prevent CRC is endoscopic polypectomy. However, adenomatous polyps are known to recur at significant rates. The aim of surveillance programs after polypectomy is to further reduce the incidence of CRC in individuals where precancerous lesions have been identified and treated. However, the medical risks and the costs of repeated examinations must be kept as low as possible. Therefore, the identification of patient subgroups with a particular low cancer risk who may be followed-up less frequently seems important. There is recent evidence that other colorectal lesions, namely flat and depressed type adenomas (F&D adenoma) and possibly some hyperplastic polyps and serrated adenomas may also carry a malignant potential which could influence our screening, treatment and surveillance strategies for the colorectum in the future. General surveillance guidelines regarding these entities have not been issued to date. This article will first discuss the biology, natural history, present surveillance recommendations and future issues for sporadic adenomatous polyps. Then, recent literature on F&D type adenomas, hyperplastic polyps and serrated adenomas will be reviewed with respect to their malignant potential and the potential necessity for treatment and surveillance of these lesions.     

Symptomatic intracerebral hematomas in posterior circulation stroke patients anticoagulated with heparin

Background: A lot of clinicians use heparin in patients with posterior circulation stroke. Frequency and risk factors of symptomatic intracerebral hematoma (ICH) in posterior circulation infarct patients anticoagulated with unfractionated heparin are not known. Methods: To determine the incidence and the risk factors of the heparin-related ICH in posterior circulation infarct patients, we retrospectively reviewed the clinical features of 37 patients who had acute posterior circulation infarct and received intravenous heparin after they underwent brain computed tomographic scans and diffusion-weighted imaging (DWI). Follow-up brain scans were obtained at any time if clinical symptoms worsened. Volumes of acute posterior circulation infarction were calculated on DWI. Results: Of 37 patients, four (10.8%) developed symptomatic ICH during heparin infusion. The location of ICH was cerebellum in all the hemorrhagic worsening patients. We found that the size of an acute infarction calculated on DWI is the risk factor of symptomatic ICH during intravenous heparin therapy in patients with posterior circulation infarct. Conclusions: Until a large prospective study is performed, it may be prudent to avoid heparin infusion in patients with large posterior circulation infarct documented on DWI.     

Therapy insight: approaching endoscopy in anticoagulated patients

Over the past decade, the application of anticoagulant and antiplatelet agents for various cardiovascular and hematologic conditions has become more widespread. Optimal management of these agents during the periendoscopic period requires consideration, but limited prospective data mean that guidelines have largely relied on expert opinion. Elective procedures should be delayed in patients on temporary anticoagulation therapy (e.g. those with deep vein thrombosis). For procedures considered to have a low risk of bleeding (e.g. diagnostic endoscopy and colonoscopy without polypectomy) there is no need to discontinue or adjust anticoagulation. For procedures with a higher risk of bleeding (e.g. polypectomy and biliary sphincterotomy) an individual approach is required. This approach might include stopping oral anticoagulant therapy with or without the administration of unfractionated heparin or low-molecular-weight heparin for the preprocedure and postprocedure periods, during which the patient's international normalized ratio is in the subtherapeutic range.     

Effect of hypertension on anticoagulated patients with atrial fibrillation.

AIM: To test the hypothesis that stroke and systemic embolic events (SEE) in the Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation (SPORTIF) III and V trials were related to blood pressure, and that differences in event rates (stroke and SEE, bleeding) could also be related to the degree of hypertension. METHODS AND RESULTS: A cross-sectional, longitudinal analysis was conducted, using data from the SPORTIF III and V trials. Results showed an increasing rate of stroke and SEE with increasing quartiles of systolic blood pressure (SBP) in AF patients. For the top quartile of SBP compared with the lowest quartile, the hazard ratio (HR) for stroke and SEE was 1.83 (95% confidence intervals [CI]: 1.22-2.74), whereas mortality was lower in the top quartile (HR 0.64; 95% CI: 0.49-0.83). In the combined SPORTIF III and V cohort, the event rate for stroke/SEE increased markedly at mean SBP of > 140 mmHg. There was no relationship between bleeding and quartiles of BP. The proportion of subjects with mean systolic BP > or = 140 mmHg was 35.8% (1220/3407) in SPORTIF III and 20.6% (807/3922) in SPORTIF V (P < 0.0001). CONCLUSION: Hypertension contributes to increased stroke and SEE in AF. Event rates markedly increase at SBP levels of > or = 140 mmHg. The higher stroke rates observed in SPORTIF III compared with SPORTIF V may be related to the greater proportion of subjects with SBP > or = 140 mmHg during the trial.