Endoscopic procedures in patients with disorders of hemostasis
- Patrick S Kamath, MD
Patrick S Kamath, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
Gastroenterologic procedures are commonly performed in patients with abnormal hemostasis. However, there are limited data assessing the bleeding risk of specific procedures in these settings.
This topic will review the bleeding risks associated with endoscopic procedures, the risk of thromboembolic complications associated with various conditions, and the periprocedural management of patients with von Willebrand's disease, hemophilia, renal failure, liver failure, and thrombocytopenia. The management of patients taking anticoagulants or antiplatelet agents is discussed elsewhere. (See "Management of anticoagulants in patients undergoing endoscopic procedures" and "Management of antiplatelet agents in patients undergoing endoscopic procedures".)
The American Society for Gastrointestinal Endoscopy (ASGE) has issued official guidelines based upon the available evidence and consensus opinion . The recommendations in this topic review are consistent with the ASGE guidelines. In addition, this topic review also addresses disorders of hemostasis not covered by the ASGE guidelines. This topic is also addressed in reviews from the American Journal of Gastroenterology and the Journal of the American College of Cardiology, which make similar recommendations [2,3].
PROCEDURE-RELATED BLEEDING RISK
The ASGE classifies the risk of bleeding from endoscopic procedures in patients with normal coagulation status as either high or low (table 1) (see appropriate topic reviews).
●High-risk procedures (risk of bleeding 1 to 6 percent) include:
- ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83:3.
- Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol 2009; 104:3085.
- Becker RC, Scheiman J, Dauerman HL, et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol 2009; 54:2261.
- Sawhney MS, Salfiti N, Nelson DB, et al. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 2008; 40:115.
- Rosen L, Bub DS, Reed JF 3rd, Nastasee SA. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 1993; 36:1126.
- Kim HS, Kim TI, Kim WH, et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 2006; 101:1333.
- Friedland S, Sedehi D, Soetikno R. Colonoscopic polypectomy in anticoagulated patients. World J Gastroenterol 2009; 15:1973.
- Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of the prevalence of von Willebrand's disease. Blood 1987; 69:454.
- Brinkhous KM, Sandberg H, Garris JB, et al. Purified human factor VIII procoagulant protein: comparative hemostatic response after infusions into hemophilic and von Willebrand disease dogs. Proc Natl Acad Sci U S A 1985; 82:8752.
- Van Os EC, Kamath PS, Gostout CJ, Heit JA. Gastroenterological procedures among patients with disorders of hemostasis: evaluation and management recommendations. Gastrointest Endosc 1999; 50:536.
- Srivastava A. Dose and response in haemophilia--optimization of factor replacement therapy. Br J Haematol 2004; 127:12.
- Eberst ME, Berkowitz LR. Hemostasis in renal disease: pathophysiology and management. Am J Med 1994; 96:168.
- Rabelink TJ, Zwaginga JJ, Koomans HA, Sixma JJ. Thrombosis and hemostasis in renal disease. Kidney Int 1994; 46:287.
- Steiner RW, Coggins C, Carvalho AC. Bleeding time in uremia: a useful test to assess clinical bleeding. Am J Hematol 1979; 7:107.
- Escolar G, Cases A, Bastida E, et al. Uremic platelets have a functional defect affecting the interaction of von Willebrand factor with glycoprotein IIb-IIIa. Blood 1990; 76:1336.
- Gawaz MP, Dobos G, Späth M, et al. Impaired function of platelet membrane glycoprotein IIb-IIIa in end-stage renal disease. J Am Soc Nephrol 1994; 5:36.
- Krishna SG, Rao BB, Thirumurthi S, et al. Safety of endoscopic interventions in patients with thrombocytopenia. Gastrointest Endosc 2014; 80:425.
- SOCIETY GUIDELINES
- PROCEDURE-RELATED BLEEDING RISK
- RISK OF THROMBOEMBOLIC COMPLICATIONS
- PATIENTS TAKING ANTICOAGULANTS
- PATIENTS TAKING ANTIPLATELET AGENTS
- INHERITED DISORDERS OF HEMOSTASIS
- von Willebrand disease
- Hemophilia A and B
- ACQUIRED DISORDERS OF HEMOSTASIS
- Renal failure
- Liver failure
- - Causes of coagulopathy
- - Evaluation
- - Treatment
- SUMMARY AND RECOMMENDATIONS