Use of Hemostatic Clips in Patients Undergoing Colonoscopy in the Setting of Coumadin Anticoagulation Therapy

Abstract

Background: Coumadin anticoagulation (CAC) presents a significant dilemma in the performance of colonoscopy. ASGE guidelines have suggested management options, but no consensus exists regarding resumption of CAC which increases the risk of post-polypectomy hemorrhage by 5 fold (GIE 2004;59:44). Definitive hemostasis at the time of polypectomy might permit minimal or no interruption of CAC. An IRB approved, multi-departmental, prospective study is presented. Patients and Methods: Patients (pts) on CAC referred for colonoscopy were identified as low-risk or high-risk for interruption of CAC by ASGE criteria. Low-risk pts held CAC 4 days; high-risk held CAC for only 48 hours, with no heparin initiated. During colonoscopy, all polypectomy sites larger than forceps biopsies were treated with either hemostatic clips (Tri Clip (Cook Medical), QuickClip (Olympus), Resolution Clip (Microvasive)) or Endoloops (Olympus). Definitive hemostasis was judged as ideal, satisfactory, or unsatisfactory. Resumption of CAC depended on the success of hemostasis. The option of post-polypectomy heparin therapy was considered on an individual basis. Follow-up was by telephone at 1, 7 and 30 days. Results: 71 (M = 44, F = 27) pts (low-risk n = 53, high-risk n = 18) enrolled from 02/05-11/05. 45/71 pts had polyps (29/45 (64%) had at least 1 adenoma). Total number of polyps removed: n = 105 (mean = 2.3, median = 2, range 1 to 10). Total number of clips used: n = 111 (QuickClip n = 54, Resolution Clip n = 30, Tri Clip n = 27), Endoloop n = 2. Mean number of hemostatic device per polyp was 1.1 and per patient was 2.5. Definitive hemostasis was judged to be ideal or satisfactory in 44/45 (98%) and unsatisfactory 1/45 (2%). Mean INR values at the time of procedure: low-risk pts 1.4 (range 1.1 - 2.8), high-risk pts 1.6 (range 1.1 - 2.6). CAC was immediately resumed in 65 of 71 pts (92%). 6 pts had a delay in resuming coumadin for 2 to 4 days due to the removal of large sessile polyps or physician preference. In follow-up, there was 1 case of a moderate LGIB reported at post-procedure day 21. No pts were hospitalized for heparin or experienced a thromboembolism. Conclusions: Patients receiving coumadin can safely undergo colonoscopy with or without polypectomy, by brief interruption of Rx and employing definitive mechanical hemostasis if polypectomy is needed. Immediate re-anticoagulation can generally be advised without a significant risk of delayed post-polypectomy bleeding. Favorable results were noted in both the low-risk (4 day hold) and high-risk (2 day hold) groups. Reimbursement to cover the costs of clips should be provided by third-party payers.