Luminary Learning Gastrointestinal Disorder- Issue 1

40  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS the anticoagulation was interrupted in patients with atrial fibrillation, the risk of a periprocedural thromboembolic events and stroke within 30 days was low with 0.7% and 0.3% respectively [28]. On the other hand, the respective risk is very high if there is a mechanical heart valve or a recent status postpercutaneous coronary intervention. Careful interdisciplinary communication and discussion are critical to optimize outcomes. Ideally, maintenance anticoagulation with warfarin or newer direct thrombin or factor Xa inhibitors (e.g., dabigatran, rivaroxaban) should be paused 5–7 days and 2–3 days before the colo- noscopy, respectively, and bridged with subcutaneous injections of unfractionated heparin or low-molecular-weight heparin. Depending on the extent of procedural intervention, the baseline medications may be resumed after 0–5 days. Routine antiplatelet agents for general prophylaxis should be discontinued 7–10 days prior to the procedure and again depending on the degree of intervention can be resumed right away if no polypectomy was done, or after 3–5 days if one was performed. In case of a more critical need for single or dual antiplatelet agents or a nonelective procedure, it might be acceptable to proceed with continued medications for low-risk procedures, and to either postpone noncritical polypectomies or assure more careful hemostasis including application of clips to the polypectomy site. Dual antiplatelet therapy is common after cardiovas- cular interventions, particularly after placement of bare metal stents or drug-eluting stents; it is generally advisable to postpone elective procedures 1–12 months if clinically acceptable or to limit colonoscopy to diagnostic efforts only, even if some pathology were to be identified. Colonoscopy During Pregnancy There is never an indication for a pure colon screening during pregnancy. However, a need may arise for a diagnostic or therapeutic colonoscopy in that period. As with any intervention, the use of colonoscopy is contraindicated in situations where the risks to the patient or the fetus outweigh the expected benefits of the colonoscopy. While it is generally considered safe to perform a needed colonoscopy after the first trimester of pregnancy, it should be determined whether the indication is of such urgency that it cannot be postponed until after delivery [29]. Occasionally, however, a woman’s condition is of such great concern that only the use of colonoscopy would have a reason- able chance to lead to an immediate resolution of the patient’s ailment or establishing a needed diagnosis. Under such circumstances, the inherent procedural and sedation risks to the patient and the unborn fetus would be acceptable [29]. IBD—Screening and follow-up Pouchoscopies Chronic inflammatory bowel disease poses a high risk for development of CRC. Routine surveil- lance with systematic biopsies is therefore recommended to start no later than 7–8 years after onset of the disease, in order to monitor for dysplasia—a cancer precursor. Restorative procto- colectomy eliminates the majority of the disease and the majority of the cancer risk [30]. However, there is a residual risk of cancer formation within the anal transitional zone cuff (even if a muco- sectomy has been performed) and in any surgically constructed small bowel reservoir (ileo-anal