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Continuing Medical Education Questions: April 2022

Carpenter, Steven L. MD, FACG

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The American Journal of Gastroenterology: April 2022 - Volume 117 - Issue 4 - p 539
doi: 10.14309/ajg.0000000000001678
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Describe the management of anticoagulants and antiplatelet agents in the setting of acute gastrointestinal bleeding as well as in the peri-endoscopic period.


A 72-year-old woman is evaluated in the emergency department after she passed a large amount of bright red blood per rectum at home and became lightheaded. She had a second large bloody bowel movement in the emergency department. She has a history of atrial fibrillation. She had a pulmonary embolus 5 years ago. She currently takes warfarin 7.5 mg by mouth (po) daily. Her prior colonoscopy was notable for diverticulosis.

On physical examination, blood pressure is 75/45 mm Hg, heart rate is 115/minute and other vital signs are normal. Her abdominal exam is unremarkable.

Laboratory studies reveal a hemoglobin level of 7.5 g/dL (90 g/L) and an international normalized ratio (INR) of 6.2. One unit of packed red blood cells and intravenous (IV) fluids have been ordered and she has 2 large bore IV catheters in place.

Which is the most appropriate next step in management?

  • A. Colonoscopy within 8 hours with cleansing enemas
  • B. Two units of fresh frozen plasma
  • C. Prothrombin complex concentrate administration
  • D. Vitamin K 5 mg intravenously


A 65-year-old man is referred for surveillance colonoscopy. He had a 15mm sigmoid colon tubular adenoma endoscopically resected 5 years ago. He has a history of coronary artery disease and underwent coronary stent placement 18 months ago. Medications include clopidogrel 75 mg po daily and aspirin 81 mg po daily. Additionally, he is on warfarin 7.5 mg po daily as he underwent prosthetic aortic valve replacement 5 years ago.

What is the recommended approach to managing his anticoagulant and antiplatelet agents in the peri-endoscopic period?

  • A. Discontinue clopidogrel and warfarin and continue aspirin, bridging with low molecular weight heparin
  • B. Continue clopidogrel, aspirin, and warfarin
  • C. Discontinue clopidogrel, hold warfarin for 5 days, and continue aspirin
  • D. Hold warfarin for 5 days, continue clopidogrel and aspirin


A 55-year-old man is hospitalized with melena for the past 24 hours. He reports no hematochezia, hematemesis, chest pain, or shortness of breath. He has osteoarthritis for which he takes naprosyn. Current meds also include apixaban 5 mg po twice a day for atrial fibrillation. Additionally, he is on clopidogrel 75 mg po daily and aspirin 81 mg po daily for coronary artery disease and a coronary stent placed 2 years ago. On examination, his blood pressure is 95/70 mm Hg, other vital signs are normal. No stigmata of chronic liver disease are noted. Laboratory studies show a hemoglobin level of 7.3 g/dL (73 g/L).

Along with resuscitation with fluids and packed red blood cells, which of the following is the most appropriate management?

  • A. IV andexanet alfa
  • B. Prothrombin complex concentrate administration
  • C. Platelet transfusion
  • D. Continue aspirin

© 2022 by The American College of Gastroenterology