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Anticoagulants and Band Ligation of Hemorrhoids (continued):

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Anticoagulants and Band Ligation of Hemorrhoids (continued):

As you can see from the bullet points included in the body of the Banding Bulletin, there are lots of recommendations concerning anticoagulants and band ligation of hemorrhoids, but little data to back them up.  As the latest guidelines are not much help either, we can only share our own personal experiences.   In our practice, we would contact whomever was ultimately responsible for the patient’s anticoagulation to discuss their clinical situation.  We would typically receive one of three types of responses:

  1. “That guy should’ve been off of his Coumadin 6 months ago!” This is obviously an easy decision to make . . .. we’d tell the patient to stop the anticoagulation per their doctor’s instructions and band away.
  2. “The indications for anticoagulation are pretty soft . . . . I’d hold them for the banding.” We would confirm that there were no undue risks, and if not, consider stopping the anticoagulation on the day of the procedure, keeping them off for 7 days for warfarin and 10 days for clopidogrel.  We’d be nervous about bouncing the patients on and off of their meds, so we’d typically wait 4 – 6 weeks between bandings, and if there was no spasm or hint of a fissure, and if the patient tolerated the first banding without issue, we might violate our “1 hemorrhoid at a setting” rule and accept the increased risk of pain in order to lessen the risk of d/c-ing the anticoagulants for a 3rd cycle.
  3. “The patient is at risk for . . . . . (an MI, a CVA, PE, etc.) and I think that they really need their anticoagulation”. At this point, we need to do a risk-benefit analysis, balancing the risks of holding their meds vs. the risk of not treating the hemorrhoids.

Consider the following case that illustrates this common dilemma…  A patient in their late 40s, s/p 2 cardiac stents placed, was taking clopidogrel, and had terrible hemorrhoidal bleeding, seemingly worsened by the fact that he was on clopidogrel.  He absolutely could not stop the anticoagulation because of the stents, but his hemorrhoid bleeding was worsened by that same clopidogrel, causing hospitalization and even transfusion.  The decision was made that the risks of not banding seemed to outweighed the risks of banding, and so the patient was examined, and the left lateral hemorrhoid banded.

The patient did well for a couple of days but then called on day 3 complaining of significant bleeding.  We met him in the ER, and it turns out the bleeding was coming from the right anterior hemorrhoid (the LL was dry), and so the RA was banded. After a brief observation, the patient was released.  4-5 days later, the patient complained of severe bleeding again.  This time, it was coming from the RP hemorrhoid, so additional bands were placed.  Remarkably, the post banding bleeding was not coming from the banded tissue, but rather from the tissue that had yet to be banded!  This experience has led me to believe that like most other healthcare decisions, when the risk of acting is greater than not acting, we stand down, and when the reverse is true, we fully consent the patient, acknowledge at least the potentially increased risk of bleeding and treat the patient per their wishes.

We wish that we could say that there are clear-cut, universally accepted guidelines to help us with these decisions, but the above algorithm has been helpful to us in our own practices.

Thanks for reading, and please let ME know if any other questions pop up or if we can help in any way.

Best,
Mitch

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