prophylaxis of cardiovascular and cerebrovascular thromboembolic disease

Anticoagulants and antiplatelet agents are increasingly employed for primary and secondary prophylaxis of cardiovascular and cerebrovascular thromboembolic disease and venous thromboembolism. Therapeutic endoscopy is also evolving and becoming more widely used. The management of anticoagulation during endoscopy is complex, because a wide variety of clinical situations need to be considered. This might explain why the attitudes of physicians on this issue vary greatly. One must balance the risk of thromboembolism from withholding the medication with the likelihood of bleeding during and after the procedure. A rational decision can be made only if the risks of thrombosis and bleeding, and the resulting morbidity and mortality, can be quantified.

PROCEDURE RISKS

Endoscopic techniques can be classified into those with high and low risks for bleeding (Table 1). Low-risk procedures include diagnostic esophagogastroduodenoscopy (EGD), colonoscopy (even with biopsy), endoscopic retrograde cholangiopancreatography (with stent insertion but without sphincterotomy), endosonography (EUS), and push enteroscopy. For example, the risk of bleeding during EGD has been estimated at 0.03%. You deserve best quality care that costs less money than you could expect: all you need at this point is to discover very low prices on prescription drugs that do not require a prescription: buy levitra professional for wisest customers.

High-risk procedures include gastric polypectomy (which has a 4% risk of bleeding), colonoscopic polypectomy (0.2% to 3%), mucosectomy from the esophagus, stomach or colon, endoscopic sphincterotomy (2.5% to 5%), ampullectomy, taking of macrobiopsies, laser mucosal ablation and coagulation (up to 6%) and the treatment of varices. In addition, several procedures can induce bleeding that is difficult or impossible to control endoscopically: bougienage or pneumatic dilation of strictures, EUS-guided fine-needle aspiration or therapy, cyst-enterostomy and percutaneous endoscopic gastrostomy.

TABLE 1 Risk of bleeding during endoscopic procedures

High (greater than 1%) Low (less than 1%)
Polypectomy EGD (± biopsy)
gastric (4%) Sigmoidoscopy (± biopsy)
colonic (0.2% to 3%) Colonoscopy (± biopsy)
Mucosectomy (2% to 5%) ERCP without dilation or
Endoscopic sphincterotomy (2% to 3%) sphincterotomy
Ampullectomy Diagnostic EUS
Treatment of varices Enteroscopy
PEG* Polypectomy with use of a
Fine needle aspiration (by EUS)* detachable snare^
Pneumatic dilation* Esophageal stenting
EUS-guided therapy*

*These procedures may induce bleeding that cannot be controlled endoscop-ically. f This is not proven but could reduce the risk of polypectomy when the polyp is pedunculated. EGD Esophagogastroduodenoscopy; ERCP Endoscopic retrograde cholangiopancreatography; EUS Endoscopic ultrasound; PEG Percutaneous endoscopic gastrostomy; ± With or without