Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding

Joanna Peloquin, Siamak M. Seraj, Lindsay Y. King, Emily J. Campbell, Ashwin N. Ananthakrishnan, James M. Richter

Research output: Contribution to journalArticle

Abstract

Background: Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. Methods: A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. Results: A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.

Original languageEnglish (US)
JournalAmerican Journal of Medicine
DOIs
StateAccepted/In press - 2016

Fingerprint

International Normalized Ratio
Endoscopy
Hemorrhage
Colonoscopy
Therapeutics
Digestive System Endoscopy
Capsule Endoscopy
Melena
Platelet Aggregation Inhibitors
Warfarin
Natural History
Medical Records
Anemia
Referral and Consultation
Logistic Models
Prospective Studies
Acids

Keywords

  • Anticoagulation
  • Gastrointestinal bleeding
  • Supratherapeutic INR
  • Warfarin

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding. / Peloquin, Joanna; Seraj, Siamak M.; King, Lindsay Y.; Campbell, Emily J.; Ananthakrishnan, Ashwin N.; Richter, James M.

In: American Journal of Medicine, 2016.

Research output: Contribution to journalArticle

Peloquin, Joanna ; Seraj, Siamak M. ; King, Lindsay Y. ; Campbell, Emily J. ; Ananthakrishnan, Ashwin N. ; Richter, James M. / Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding. In: American Journal of Medicine. 2016.
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abstract = "Background: Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. Methods: A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. Results: A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54{\%} of patients, and 60{\%} of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18{\%}), with endoscopic intervention in only 26 patients (25{\%}). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.",
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