Task Force 4: Inpatient Management of Patients with MCSD - The ...

amenable to endoscopic or surgical intervention, then alterations of the goal INR or the
number, dosage, or even presence of antiplatelet agents may need to be considered.
While patients with continuous flow pumps have been managed for long periods without
warfarin in the setting of recurrent gastrointestinal bleeds, this approach must be
weighed against the risk of thromboembolism or pump thrombosis for each patient,
pump, and clinical setting. As previously noted, reduced pulsatility has been implicated
in the development of arteriovenous malformations. Therefore, some have advocated
decreasing pump speed to increase pulsatility as a mechanism to address bleeding
from arteriovenous malformations. To date, the effectiveness of such a strategy or the
target degree of pulsatility is not known. There are few data on strategies such as
hormonal therapy, octreotide, or replacement of vWF.
Recommendations for the Evaluation and Management of Patients who Present
with Recurrent Episodes of Gastrointestinal Bleeding:
Class I:
1. Repeated endoscopic evaluation should take place in consultation with
gastroenterology consultation.
Level of Evidence: C.
2. In the setting of recurrent gastrointestinal bleeding with no source or a source
that is not amenable to therapy, the type and intensity or even the use of
antiplatelet therapy should be reevaluated in the context of the bleeding severity
and pump type.
Level of Evidence: C.
3. In the setting of recurrent gastrointestinal bleeding with no source or a source
that is not amenable to therapy, the goal INR or even the continued use of
warfarin should be reevaluated in the context of the bleeding severity and pump
type.
Level of Evidence: C.
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