Incidence and predictors of bleeding or thrombosis after polypectomy in patients receiving and not receiving anticoagulation therapy

Abstract

Summary. Background and aims: To assess the effect of warfarin anticoagulation therapy (AC) on the incidence of colon bleeding after elective colonoscopy with polypectomy and to identify independent predictors of post-polypectomy colon bleeding. Methods: This was a retrospective cohort analysis. Patients interrupting warfarin AC therapy for polypectomy (AC group) were matched on age (± 3 years) with up to two patients who underwent polypectomy but were not receiving AC (non-AC group). Data were extracted from electronic medical, pharmacy and laboratory claims and records and manual medical chart review. Incidence rates of colon bleeding requiring hospitalization, other gastrointestinal bleeding, thrombosis and death in the 30 days post-polypectomy were compared between groups. Multivariate regression techniques were used to identify independent predictors of post-polypectomy colon bleeding. Results: A total of 425 AC group patients were matched to 800 non-AC group patients. Post-polypectomy colon bleeding occurred more often in AC group patients (2.6% vs. 0.2%, P = 0.005). There were no differences in the rates of other outcomes (P > 0.05). Independent predictors of colon bleeding included AC group status [adjusted odds ratio (AOR) = 11.6; 95% confidence interval (CI) = 2.3-57.3], number of polyps removed (AOR = 1.2; 95% CI = 1.1-1.4) and male gender (AOR = 9.2, 95% CI = 1.1-74.9). Conclusions: The incidence of post-polypectomy colon bleeding was higher in patients receiving AC even although warfarin was interrupted for the procedure. Independent predictors of colon bleeding were identified as: receiving AC, removal of multiple polyps and male gender. Our findings suggest that additional methods to reduce the likelihood of post-polypectomy colon bleeding in AC patients should be investigated.

Risk of Bleeding After Percutaneous Endoscopic Gastrostomy (PEG)

“…Although anticoagulation has been linked to postpolypectomy bleeding [3,38,39,42], no studies have found any statistically significant association between intravenous heparin infusions and post-PEG bleeding.…”

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

“…9 11-14 Routine discontinuation of warfarin therapy may therefore be considered necessary in most colonoscopy services. Even when temporarily discontinued, warfarin therapy is associated with an increased risk of post-polypectomy bleeding (PPB) 15 and patients should be advised of this.…”

Optimal timing of anticoagulation pre- and post-colonoscopy with polypectomy

“…Their practice was to stop warfarin 4 days prior to colonoscopy and restart it immediately after the procedure. Friedland et al [9] reported a 0.8% incidence of major post-polypectomy bleeding requiring transfusion while holding warfarin 36 h before the procedure. Little to no information is available on the management of clopidogrel therapy, although some studies suggest that there may be a higher risk of bleeding when aspirin and clopidogrel are being used simultaneously [13].…”

“…The risk of post-polypectomy bleeding has been found to be higher in patients receiving anticoagulation despite interruption of therapy [8]. However, Friedland et al [9] found a very low risk of bleeding 0.8% when small polyps (less than 1 cm) were removed in patients without interruption of anticoagulation. Recent studies have found no increased risk of post-polypectomy bleeding in patients on NSAIDs and aspirin [4,7].…”