GASTROENTEROLOGY ARTICLE OF THE WEEK
September 15, 2011
Ben-Menachem T, Dominitz JA. Acute upper gastrointestinal hemorrhage in an elderly woman taking aspirin and copidogrel. Clin Gastroenterol Hepatol 2011;9:649-652.
1. A patient with a high trombotic risk (recent stents) has UGIB. Your endoscopy shows a duodenal ulcer with visible vessel, successfully injected and clipped, you recommend:
a. Start DAT immediately
b. Stop DAT permanently
c. Start ASA, do not give clopidogrel or other antiplatelet agent ever, add PPI
d. Use heparin instead, preferably subcutaneously
e. Stop DAT for 2-7 days, then resume with PPI
f. Stop DAT for 2-7 days, then resume with ranitidine to avoid PPI-clopidogrel
interaction
2. A patient comes to your office on his 50th birthday. He had coronary stents placed 1 month ago and is on ASA and clopidogrel. He requests a screening colonoscopy as a birthday present. After singing happy birthday to him you:
a. stop the clopidogrel, continue ASA, do the colonoscopy
b. Tell him to come back with a cake on his 51st birthday to schedule the colonoscopy, promise you will sign happy birthday to him again then.
c. Do the colonoscopy and hope to find no polyps
d. Stop the ASA, continue the clopidogrel, do the colonoscopy
e. Use a heparin window and do the colonoscopy
f. Continue ASA, continue clopidogrel, do the colonoscopy, take out polyps, be happy, don’t worry.
True or False
3. Diagnostic endoscopy is safe for patients taking dual antiplatelet therapy, as long as biopsies are not done
4. A patient with ACS and brown heme positive stool should undergo colonoscopy before cardiac catheterization.
5. 30-day after starting dual antiplatelet therapy, risk of GI bleeding is 1.3% in average risk patients, 12% in those with prior history of GI bleed
6. Routine endoscopy 12 weeks after starting aspirin therapy shows ulcers in 7% to 10% and erosive disease in up to 47% of individuals
7. Clopidogrel alone does not increase the risk of GI bleeding, however, the combination of aspirin and clopidogrel is worse than aspirin alone.