Can dilatation and curettage with polypectomy be performed in a patient with heavy bleeding who is on anticoagulants?

Dilatation and Curettage with Polypectomy in Anticoagulated Patients with Heavy Bleeding

Dilatation and curettage (D&C) with polypectomy can be performed in patients on anticoagulants who present with heavy bleeding, but the procedure should be undertaken with specific anticoagulation management strategies to minimize hemorrhagic complications while addressing the urgent clinical indication.

Critical Context: Emergency vs Elective Setting

The question describes a patient with heavy bleeding, which fundamentally changes the risk-benefit calculation. In this emergency scenario, the bleeding itself is the primary threat to morbidity and mortality, and the D&C with polypectomy is the therapeutic intervention to control it.

Anticoagulation Management Strategy

For Direct Oral Anticoagulants (DOACs)

• Omit the morning dose of DOAC on the day of the procedure to allow an adequate safety margin, regardless of whether it's a once-daily or twice-daily regimen 1
• DOACs have unpredictable anticoagulant effects at the time of endoscopy due to variable peak levels 2-6 hours after administration, and there is no reliable test to measure anticoagulation 1
• The rapid offset of DOACs (typically 12-24 hours) means that delaying the morning dose provides meaningful reduction in bleeding risk without requiring bridging 1

For Warfarin

• Avoid heparin bridging in this setting, as bridging is associated with significantly higher bleeding rates (12.0% with bridging vs 4.7% without) 1
• An RCT demonstrated that cold polypectomy on continued anticoagulation had lower major bleeding rates than bridging with unfractionated heparin 1
• If warfarin must be interrupted for the procedure, bridging should not be used based on British Society of Haematology guidelines 1

For Antiplatelet Agents

• Aspirin monotherapy can be safely continued during polypectomy procedures 1
• Clopidogrel is associated with increased delayed bleeding risk (pooled relative risk 4.66,95% CI 2.37-9.17) 1
• For clopidogrel, consider temporary substitution with aspirin 7 days prior if the procedure can be delayed, though this may not be feasible in emergency bleeding 1

Procedural Technique Considerations

Cold Snare vs Hot Snare

• Cold snare technique is strongly preferred for patients on anticoagulation, as it dramatically reduces bleeding risk 1
• In an RCT of anticoagulated patients with polyps <1 cm, cold snare had 0% delayed hemorrhage requiring intervention compared to 14% with hot snare 1
• Immediate hemorrhage rates were also lower with cold snare (5.7% vs 23.0%) 1

Hemostatic Measures

• Prophylactic clipping after polypectomy may reduce bleeding risk, though evidence is mixed 1
• Submucosal injection of diluted epinephrine may reduce post-polypectomy bleeding 1
• Caution with prophylactic clips on pedunculated polyps, as one RCT was terminated early due to complications including perforation (1.5%) and mucosal burns (4.5%) 1

Risk Stratification Factors

Patient-Specific Risks

• Polyp size >1 cm significantly increases bleeding risk (adjusted OR 4.5,95% CI 2.0-10.3) 1
• Comorbidities increase risk: diabetes (OR 2.5), coronary artery disease (OR 3.0), hypertension (5-fold increased risk), and COPD (OR 2.2) 1
• Advanced age increases transfusion requirements after post-polypectomy bleeding 1

Anticoagulant-Specific Risks

• Warfarin users have higher immediate bleeding rates compared to controls (13.7% vs 0.9%, p<0.001) 2
• DOAC users have similar bleeding rates to warfarin (13.7% vs 13.7%) 2
• Apixaban appears to have lower bleeding risk than other DOACs: lower than dabigatran (aHR 2.23) and rivaroxaban (aHR 2.72) 3

Clinical Decision Algorithm

Step 1: Assess Urgency

• If heavy bleeding is causing hemodynamic instability or significant anemia, proceed urgently with D&C and polypectomy 1
• The therapeutic benefit of stopping active hemorrhage outweighs procedural bleeding risk in this emergency context

Step 2: Optimize Anticoagulation Timing

• For DOACs: Omit morning dose on procedure day 1
• For warfarin: Check INR if time permits; do NOT use heparin bridging 1
• For aspirin: Continue without interruption 1
• For clopidogrel: Accept increased bleeding risk given emergency indication 1

Step 3: Use Cold Snare Technique

• Employ cold snare polypectomy whenever technically feasible to minimize bleeding risk 1
• Avoid hot snare and pure cutting current in anticoagulated patients 1

Step 4: Apply Hemostatic Measures

• Consider prophylactic clipping for larger polyps (>1 cm) 1
• Have epinephrine injection and cautery equipment immediately available 1

Common Pitfalls to Avoid

• Do not use heparin bridging for warfarin interruption, as this increases bleeding risk 2.5-fold without reducing thrombotic events 1, 4
• Do not assume all DOACs have equal bleeding risk: apixaban has significantly lower rates than dabigatran and rivaroxaban 3
• Do not restart anticoagulation too early: restarting within 1 week post-polypectomy increases bleeding risk (OR 4.50) 4
• Do not use hot snare technique in anticoagulated patients, as this increases delayed bleeding from 0% to 14% 1
• Remember delayed bleeding can occur up to 30 days after polypectomy, with most cases in the first 2 weeks 5

Post-Procedure Management

• Restart anticoagulation cautiously, ideally after 1-2 weeks if clinically feasible 5, 4
• For urgent cardiac indications requiring earlier anticoagulation resumption, consider carefully monitored IV unfractionated heparin rather than LMWH 5
• Monitor for delayed bleeding, which typically presents as large-volume bloody bowel movements 1