Should Anticoagulants Be Stopped After Hemorrhoid Ligation?

Should anticoagulants be discontinued after hemorrhoid ligation?

My father underwent a colonoscopy and was found to have multiple large internal hemorrhoids.
The gastroenterologist advised that no treatment was necessary, but due to severe pain, he consulted a colorectal specialist.
The colorectal specialist noted that the rectum was distended and there was a diverticulum present.
A ligation procedure was performed at that time.
However, since my father has been taking the anticoagulant Plavix (Clopidogrel) for over a year and has not been taking aspirin, we were advised to consult a cardiologist regarding whether he should discontinue the medication.
The cardiologist surprisingly told us to go back and ask the surgeon.
Currently, five days post-surgery, he has had one bowel movement with a small amount of bleeding.
Do you have any recommendations, Dr.
Ke? Thank you for taking the time to respond!

KARA, 60~69 year old female. Ask Date: 2020/10/30

Dr. Ke Fangxu reply Surgery

In fact, for patients taking anticoagulants, we generally adopt a more conservative approach, avoiding ligation if possible.
If ligation is absolutely necessary, we still recommend discontinuing the anticoagulants, as there is a very small risk of postoperative bleeding associated with hemorrhoid ligation, and this risk increases when anticoagulants are used concurrently.
Now that the ligation has already been performed, we can only observe the situation, as it takes at least three days for the medication concentration to decrease after stopping the anticoagulants.
The risk period for bleeding after hemorrhoid ligation is also about one week, so even if the medication is stopped now, it cannot reduce the drug concentration during the high-risk period.
Fortunately, during this time, your father has not experienced any significant bleeding.
It is advisable to avoid constipation in the coming days to prevent straining that could lead to bleeding from the wound.
If a ligation is needed again in the future, please discuss it in detail with the physician and carefully assess the risks.

Reply Date: 2020/10/30

More Info

When it comes to the management of anticoagulants, particularly in the context of procedures like hemorrhoid ligation, careful consideration is essential. Your father's situation, where he is on Plavix (clopidogrel) for over a year, requires a nuanced approach to ensure both the effectiveness of the anticoagulant therapy and the safety of the surgical procedure.

Anticoagulants, such as clopidogrel, are crucial for preventing thromboembolic events, especially in patients with a history of cardiovascular issues. However, they also increase the risk of bleeding, which is a significant concern during and after surgical interventions. In the case of hemorrhoid ligation, the procedure itself can lead to bleeding, and the presence of anticoagulants can exacerbate this risk.

Typically, the decision to continue or discontinue anticoagulants before a procedure depends on several factors, including the type of procedure, the patient's overall health, and the risk of thromboembolic events versus the risk of bleeding. For minor procedures like hemorrhoid ligation, many practitioners may recommend continuing anticoagulants, especially if the patient has a high risk of thrombosis. However, in cases where the risk of bleeding is significant, a temporary cessation of anticoagulants may be warranted.

In your father's case, since he has undergone a hemorrhoid ligation and is experiencing some post-operative bleeding, it is crucial to monitor the situation closely. The fact that he has had only a small amount of bleeding after one bowel movement is a positive sign, but it is essential to remain vigilant. If the bleeding increases or if he experiences any other concerning symptoms, such as dizziness, increased heart rate, or weakness, it would be prudent to seek immediate medical attention.

Regarding the communication between the surgical team and the cardiologist, it is not uncommon for there to be some back-and-forth in these situations. The surgical team may have specific protocols regarding anticoagulant management, while the cardiologist will consider the patient's cardiovascular risk. It may be beneficial to have a direct conversation with both parties to clarify the best course of action.

In summary, while it is generally advisable to consult with both the surgical and cardiology teams regarding the management of anticoagulants, the decision to stop or continue Plavix should be based on a thorough assessment of the risks and benefits. If there are any signs of increased bleeding or other complications, do not hesitate to seek medical advice. It is always better to err on the side of caution when it comes to anticoagulant therapy and surgical procedures.

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