Based on data from the CDC, over the next 20 years, approximately 12,500 patients (pt) with bleeding disorders will require a screening colonoscopy. For a 75 kg adult receiving an average factor dose of 35 units/kg, this translates into utilization of approximately 30 million units over this time period which will vary with pt weight and disease severity. In the absence of evidence based guidelines, current practice is to provide prophylactic clotting factor concentrates to all such pt. Herein we report our institutional experience.
Retrospective chart review of Mayo Comprehensive Hemophilia Treatment Center pt undergoing colonoscopies. Eligible pt had congenital von Willebrand disease (VWD), hemophilia A (HA) and B (HB). Data collected included pt demographics, factor concentrate and antifibrinolytic agent use, biopsy and polypectomy procedures, and bleeding complications (up to 1 month).
From 1993-2013, 69 pt underwent 130 colonoscopies, 40/69 (58%) were males. Median (range) age at the time of the procedure was 60 years (3 to 87). The distribution of diagnoses were as follows: HA mild n=13, moderate n=5, severe n=5 and severe with inhibitor n=1; symptomatic carrier of HA n=2; HB mild n=6, severe n=1; VWD types 1: n=23, 2A: n=5, 2B: n=5, 2M: n=2; 3: n=3.
40/69 (58%) pt had one colonoscopy, the remainder 2 to 8 colonoscopies. The procedures were performed as outpatient in 119 (92%) and as inpatient in 11 (8%). Colonoscopy indications included: GI bleeding (49/130, 38%); screening (32/130, 25%); history of polyps (24/130, 18%); iron deficiency anemia (7/130, 6%); Crohn’s disease (5/130, 4%); diarrhea (4/130, 3%); colon cancer followup (3/130, 2%); abnormal imaging (3/130, 2%); family history of colon cancer, diverticulitis, and ulcerative colitis (combined 3/130, 2%).
Of the 130 procedures, 25/130 (19%) received no factor or antifibrinolytic treatment, 58/130 (45%) received pre-procedure prophylactic factor only, 1/130 (1%) received post-procedure factor only, 29/130 (22%) received both, 3/130 (2%) received pre-factor and an antifibrinolytic, 3/130 (2%) received post-factor and an antifibrinolytic, 11/130 (8%) received pre and post-procedure factor and an antifibrinolytic. None received an antifibrinolytic alone.
Biopsy was performed in only 56/130 (43%) of colonoscopies. Types of biopsies: polyp 37/56 (66%), mucosal 11/56 (20%), mucosal & polyp 5/56 (9%), lesion 1/56 (2%), lesion & polyp 2/56 (4%). Of the pt receiving a biopsy, 39/56 (70%) received pre-procedure factor and 25/56 (45%) received post-procedure factor. The pt most likely to be biopsied were those with an indication of history of polyps 15/56 (27%), GI bleed 13/56 (23%), screening 10/56 (18%), and Crohn’s disease/colon cancer follow up/ diarrhea/iron deficiency anemia each 3/56 (5%).
Of the total number of procedures, 39/130 (30%) underwent a polypectomy. Of these, 26/39 (67%) received pre-procedure factor and 17/39 (44%) received post-procedure factor. The average number of polypectomies per patient was 2.3 and the average number of polyps removed per procedure was 3.2.
Hemorrhagic complications were noted in 26/130 procedures (13/26 procedural only, 4/26 post-procedure only, 9/26 both), of which 8/26 (31%) were major (requiring hospitalization or RBC transfusion) and 18/26 (69%) were minor (requiring factor or observation). Of all the bleeding complications observed, 15/26 (58%) received factor alone (3/15 major bleeds, 12/15 minor bleeds), 3/26 (11%) received nothing (3/3 minor bleeds), and 8/26 (31%) received a combination of factor concentrate and an antifibrinolytic (5/8 major bleeds, 3/8 minor bleeds). There were 14/56 (25%) pt who underwent a biopsy or polypectomy without receiving any pre/post factor or antifibrinolytic. In 3/14 (21%), there was a minor bleeding complication and in 0/14 (0%), there was a major bleeding complication. No pt experienced colonic perforation.
In this study, most pt did not receive a biopsy or polypectomy. A risk stratification approach could be taken when deciding on factor concentrate infusions. For low risk pt, factor could be withheld but with post-procedure infusion provided for those undergoing biopsy or polypectomy. For high risk pt, current practices are reasonable. Based on the results presented here and the potential magnitude of impact, this topic deserves further study in a prospective fashion.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.