Elsevier

Gastrointestinal Endoscopy

Volume 58, Issue 3, September 2003, Pages 369-373
Gastrointestinal Endoscopy

Original Articles
Acute GI Bleeding in the Setting of Supratherapeutic International Normalized Ratio in Patients Taking Warfarin: Endoscopic Diagnosis, Clinical Management, and Outcomes

https://doi.org/10.1067/S0016-5107(03)00010-5Get rights and content

Abstract

Background:

Acute GI bleeding is a life-threatening complication of warfarin therapy. Acute GI bleeding in patients with an international normalized ratio of 4.0 or greater (supratherapeutic) is often attributed to trivial mucosal lesions. The aim of the study was to determine the frequency of potentially significant lesions that would warrant endoscopy in this setting.

Methods:

A retrospective review was conducted of patients treated with warfarin who were admitted to a single Veterans Affairs hospital from 1996 to 2000 with acute GI bleeding. Endoscopic findings, clinical management, and outcomes are reviewed for patients with a supratherapeutic international normalized ratio (≥4.0) and compared with patients with an international normalized ratio in the therapeutic range (2.0-3.9).

Results:

Fifty-five patients with an international normalized ratio of 4.0 or greater (mean 8.4 [3.9]) and 43 patients with an international normalized ratio between 2.0 and 3.9 (mean 2.9 [0.6]) were hospitalized with acute GI bleeding. Thirty-seven patients (67%) with a supratherapeutic international normalized ratio and GI bleeding underwent upper endoscopy. Of these, 81.1% had positive findings, 18.9% had peptic ulcer disease, and 7.2% required endoscopic treatment. Thirty-eight percent of the patients with a supratherapeutic international normalized ratio underwent lower endoscopy; of these, 57.1% had abnormal findings and 9.5% required endoscopic treatment. Four patients (7.3%) in the supratherapeutic international normalized ratio group died during the index hospitalization. When patients with GI bleeding and a therapeutic international normalized ratio were compared with those with a supratherapeutic international normalized ratio, there were no significant differences between the two groups with regard to days of hospitalization, units of blood transfused, frequency of recurrent bleeding, need for surgery, or in-hospital deaths.

Conclusions:

The high frequency of clinically significant lesions in patients taking warfarin with an international normalized ratio in the supratherapeutic range and acute GI bleeding supports a role for endoscopic evaluation.

Section snippets

Study Design

This is a retrospective study of a cohort of patients treated with warfarin anticoagulation admitted to a single Veterans Affairs Medical Center with acute GIB. A standardized data collection form was designed before chart review; one investigator (T.A.R.) abstracted all charts. The electronic discharge summaries of all patients hospitalized with evidence of major acute GIB between January 1996 and December 2000 were reviewed. The start date of 1996 was selected because this was the year in

Results

By using the ICD-9-CM codes, there were 2979 hospitalizations identified as potential cases of GIB. Of these, 1248 episodes met study criteria for acute major GIB. Cross-referencing with the pharmacy database identified 165 patients (13.2%) who were taking warfarin at the time of the index episode of GIB. Of these, 7 had no INR value reported, 43 had an INR of less than 2.0, 53 had an INR in the range 2.0 to 3.9 (of which 10 charts were unavailable), and 62 had an INR value of 4.0 or greater

Discussion

Acute GIB in anticoagulated patients presents a challenge. The optimal management of these patients with regard to the role of endoscopy has not been established. Initial management for such patients is primarily the reversal of anticoagulation and the re-establishment of normal hemostatic mechanisms. This can be done safely, as symptomatic thromboembolism after transient withdrawal of long-term anticoagulation is uncommon.11 In the pre-endoscopy era, the etiology of bleeding was often

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Presented at the annual Digestive Diseases Week, May 20-23, 2001, Atlanta, Georgia (Gastrointest Endosc 2001;53:AB4391).

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