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Session III
LGS-III: Safety Issues in Colonoscopy (ASGE-KSGE)
Colonoscopy for Patients with Risks: Elderly,
Debilitated, or Receiving Antiplatelets/anticoagulants
Jong Pil Im, M.D., MPH, Ph.D.
Department of internal medicine and Liver Research Institute, Seoul National University College of
Medicine, Seoul, Korea
Introduction
The population is rapidly aging throughout most of the world, and the proportion of the elderly will continue to rise over the next decades. The World Health Organization (WHO) defines elderly as 65 years of age
and older and very elderly as 80 years of age and older. With increasing age, both benign and malignant gastrointestinal (GI) diseases rise. For example, the incidence of colorectal cancer begin to increase around 40 years,
and doubles each successive decade. Moreover, the elderly usually co‐present with age‐related comorbidities
such as cardiovascular and pulmonary dysfunction requiring various medications including antiplatelet agents
and anticoagulants. Colonoscopy is the primary method used for the evaluation and treatment of the colorectal
disease, and the number of patients referred for colonoscopy is on the rise and expected to increase. This review
will discuss some of the issues of colonoscopy for patients with risks.
Colonoscopy for elderly or debilitated patients
The indications for colonoscopy in elderly or debilitated patients are essentially the same as in other patients.
A prospective evaluation in routine clinical practice in elderly Asians showed the elderly patients had in additional one or more co‐morbid illnesses, with significantly higher rates of diabetes, ischemic heart disease, hypertension, and stroke disease.1 Therefore, the physician needs to pay more attention when considering colonoscopy after careful discussion with patients of potential benefits and risks, as well as a discussion of the implications
of patient comorbidities on life expectancy, as complications in these patients can be more catastrophic.
1. Benefits
Colonoscopy in the elderly is high‐yield, as colorectal disease is common among this age group, particularly
for colorectal neoplasia. In a prospective study with 2,000 patients, there was a significantly higher overall diagnostic yield in the elderly group (65 years or older) (65% vs. 45%, P<0.001) with higher rates of carcinoma detected (7.1% vs. 1.3%, P < 0.0001), compared with those in younger patients.2 In addition, the detection rate of
colorectal cancer was high among symptomatic patients over the age 85 years of age, while there was a relatively
low yield in asymptomatic patients.3 Therefore, there is definite benefit of colonoscopy in patients with clinical
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characteristics predicting positive findings such as increasing age, rectal bleeding, weight loss, and iron deficiency anemia.
Recently, Kahi et al. reported that colonoscopy in the preceding 10 years was associated with a significant re4
duction in colorectal cancer (CRC) incidence in a group of older individuals in both distal and proximal CRC.
A cross‐sectional study was performed to compare the prevalence of neoplasia as well as compare the mean gain
of life expectancy across patients of 50 to 54 years, 75 to 79 years, and greater than 80 years who underwent
5
screening colonoscopy. The prevalence of neoplasia was 28.6% and the highest in the 80 or more years group,
followed by 26.5% in patients of 75 to 79 years group, and 13.8% in the 50 to 54 years group. However, mean
extension in life expectancy was much lower in the octogenarians (0.13 y) than in the 50 to 54 years group (0.85 y).
Therefore, the US Preventive Services Task Force recommend against routine colorectal cancer screening in individuals of 75 to 85 years and in patients greater than 85 years of age as the benefits have not been demon6
strated to outweigh the potential harms.
2. Safety and procedural considerations
Generally, complication rates of endoscopic procedures in elderly patients are known to be similar to those
seen in younger patients. However, an exception is colonoscopy with higher perforation rates and higher rates
7
of cardiovascular, pulmonary, and total complications (Table 1). A meta‐analysis of studies of elderly patients
undergoing colonoscopy found that patients >65 years of age were at significantly higher risk for perforation
than those <65 years of age (incidence rate ratio of 1.3). In addition, compared with patients under the age of
80 years, octogenarians were at increased risk for perforation (incidence rate ratio of 1.7), cardiovascular and
pulmonary complications (incidence rate ratio of 1.7), and total colonoscopy complications (incidence rate ra8
tio of 1.8). One of the main risks in the elderly patients is the sedation used during the procedure. Elderly patients are more prone to develop hypotension, hypoxia and arrhythmias compared with younger adults. These
changes occur because of the increased residual pulmonary volumes, the increased vascular tissue elasticity and
the decreased vital capacity. In addition, the patient’s central nervous response to hypercapnia and hypoxia is
altered. Thus, sedatives such as midazolam or valium and narcotics such as meperidine or morphine can deeply
Table 1. Summary of colonoscopic complications in the elderly7
Author
Study type
Karajeh
Lukens
Arora
Prospective
Prospective
Retrospective
Total patient number
(group split)
2,000
250 (100 vs. 150)
277,434
Ko
Prospective
502
Warren
Retrospective
53,200
66–69 vs. 70–74 vs.
75–79 vs. 80–84 vs.
≥85
Ko
Prospective
18,271
≥40
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Patient age (years)
≥65 vs. <65
≥80 vs.<80
18–50 vs. 50–65 vs.
65–80 vs. ≥80
≥40
Complications
Tachycardia, bradycardia
Hypotension, desaturation
Perforation
Hypotension, hypertension, tachycardia,
bradycardia, hemorrhage, abdominal pain,
arrhythmia, fever, bloating, nausea, rash, diarrhea,
constipation, bleeding
Perforation, bleeding, ileus, nausea, vomiting,
abdominal pain, myocardial infarction/angina,
arrhythmia, congestive heart failure, cardiac or
respiratory arrest, syncope or hypotension or shock
Respiratory depression, hypotension, bradycardia,
vasovagal reaction, tachycardia, hypertension,
bleeding,
LGS-III: Safety Issues in Colonoscopy (ASGE-KSGE)
9
affect their cardiorespiratory function. In 2006, the American Society of Gastrointestinal Endoscopy issued
guidelines regarding the use of sedation in elderly patients undergoing endoscopic procedures. Because of physiological changes with aging, the guidelines recommend using fewer sedative agents at lower doses than used in
10
younger patients, and to administer the medications using slower infusion rates. Generally, elderly patients
tolerate unsedated diagnostic endoscopy better than younger patients. However, it is recommended to intensively monitor blood pressure and oxygen saturation, and oxygen supplementation must be used liberally in
11
the elderly when indicated.
Colonoscopy in the elderly has been noted to be more challenging and the adequacy of colonic preparation is
12
a particular problem. The importance of an adequate colonoscopy preparation cannot be overstated, as a poor
preparation is associated with increased chance of missed lesions, procedure failure, prolonged procedure time,
and increased procedural complications.13 When using colon preparation in elderly patients the endoscopist
needs to be cautious about the preparation substance. Two of the most widely studied colonic preparations are
polyethylene glycol and oral sodium phosphate. Guidelines caution against using sodium phosphate preparations in the elderly, especially those with renal or cardiac dysfunction.
Lukens et al found that in octogenarians and non‐octogenarians preparation tolerance (86% and 90%, re14
spectively) was similar in a prospective study involving 250 patients, including 100 octogenarians. Endoscopic
success rate was slightly lower in octogenarians (90% vs. 99%, p=0.002). However, preparation was poor in
16% of octogenarians compared with 4% of non‐octogenarians (p=0.001) independent of the type of preparation used. Age has been shown to be an independent risk factor for a poor colonic preparation, regardless of the
type of preparation.15
Colonoscopy for patients receiving antiplatelets/anticoagulants
With the increasing use of antithrombotic agents including anticoagulants and antiplatelet agents, thienopyridines (eg, clopidrogrel and ticlopidine), their management during the periendoscopic period has become a
more common and more difficult problem. Bothe the American Society for Gastrointestinal Endoscopy16 and
the European Society of Gastrointestinal Endoscopy (ESGE) published the guidelines for management antith16,17
Also, in the Korean Guidelines for
ormobotic agents in patients undergoing endoscopic procedures.
Colonoscopic Polypectomy, aspirin use during the colonoscopic polypectomy was discussed.18
Before performing endoscopic procedures on patients taking antithrombotic medications, the physician
should consider the urgency of the procedure and the risks of bleeding related solely to antithrombotic therapy,
bleeding related to an endoscopic intervention performed in the setting of antithrombotic medication use, and
16
a thromboembolic event related to interruption of antithrombotic therapy.
Colonoscopy present a minimal bleeding risk, and mucosal biopsy sampling is also associated with a very low
bleeding risk that is not increased in patients taking antithrombotic agents, so it is recommended to continue
16
the medication in the elective endoscopic setting (Fig. 1).
Endoscopic polypectomy is categorized as the higher‐risk procedures associated with an increased risk of
bleeding, including therapeutic balloon‐assisted enteroscopy, endoscopic sphincterotomy, dilation of strictures,
percutaneous endoscopic gastrostomy, and EUS‐guided FNA. Risk factors for post‐polypectomy bleeding
(PPB) include age >65 years, anticoagulation, cardiovascular disease, polyp size ≥1 cm, but aspirin does not in-
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Fig. 1. Management of antithromobotic agents in the elective endoscopic setting.16
crease the risk of PPB, irrespective of polyp size. Thus, the ESGE guideline recommend that aspirin is not discontinued irrespective of polyp size.17 However, discontinuation of aspirin is recommended in patients with no
risk of thromboembolic event, and characteristics of patients and polyp should be considered in patients with
18
low thromboembolic risks when polypectomy is necessary in Korea.
When clopidogrel and ticlopidine are used, it is suggest that these medications may be continued for diagnostic colonoscopy, but should be discontinued for approximately 7 to 10 days before elective polypecomy. The
ASGE guideline suggest discontinuing anticoagulation (ie, warfarin) in patients with a low risk of thromboembolic events in whom it is safe, and suggest continuing the anticoagulation in patients at higher risk of thromboembolic complications switching to LMWH or UFH (ie, bridging therapy) in the high bleeding risk procedure.
However, our understanding of the safety of diagnostic and therapeutic colonoscopy in patients taking antithrombotic medications is rapidly evolving as knowledge and experience are accumulated. Therefore, strong
recommendations about management of particular agents cannot be made at this time and clinicians are encouraged to consult to relevant physicians (eg, cardiology and neurology) before discontinuing any antith-
166 IDEN 2014
LGS-III: Safety Issues in Colonoscopy (ASGE-KSGE)
rombotic agent. Furthermore, discussion with the patient before the procedure is invaluable to help determine
whether antithrombotic agents should be stopped or adjusted in any particular patient with consideration of
both potential thromboembolic events that be devastating and the bleeding risk associated with endoscopic
16,17
procedures.
Conclusions
Colonoscopy in the elderly with comorbidities is generally a safe and effective procedure even for patients
greater than 80 years of age, but general measures and care must be taken for the successful and safe colono7
scopy in regard to colonic preparation, sedation issues and some complications. Although, it is advisable to be
familiar with several guidelines about periprocedural management of anti‐thrombotic agents, it should be kept
in mind that clinical decisions in any particular case involve a complex analysis of the patient’s condition and
16
available courses of action. The risks associated with procedures itself, aging, comorbidities, and medication
used must be balanced against potential benefits when performing colonoscopy in patients with multiple risks.
References
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