Frailty, MVR, RPB

Gabrielle Morris

Elderly, frail gentleman for gastroscopy and Colonoscopy – background of PR bleeding with supratherapeutic INR. Nil episodes since INR within appropriate range.

Background: 

  • CVS: 
    • OOHCA 2018 with 4x stents 
    • Metallic MVR 2004
    • Severe TR
    • AF 
  • Severe eczema + Grover’s disease (itchy rash) – recent course of prednisone 
  • Resp: OSA with CPAP 

Issues

  • CVS – Recent functional deterioration, low exercise tolerance ++  
  • Anaemia – persistent. Iron replete

Discussion

  • Perioperative Risk
    • High anaesthetic risk due to CVS morbidity
    • Physiologic stress of bowel prep and requirement for interruption of anticoagulation
  • Goals of care
    • Low likelihood of positive finding as per proceduralist (probable small bowel angiodysplasia, nil lesions on CT colonography and previous normal gastroscopy)
  • Potential for gastroscopy (without biopsies) without interruption to anticoagulation? 
  • If further bleed with appropriate INR, would we consider greater need for scope? 
  • ? patient optimized – recent deterioration ++ in exercise tolerance. Nil obvious signs of heart failure on examination. 
  • Clinicians with longer term care of this patient may be better positioned to determine how procedure aligns with goals of care

Plan

Discuss with cardiology re optimisation and bridging requirements (if requiring biopsies)