Child-Pugh B or C Cirrhosis Increases the Risk for Bleeding Following Colonoscopic Polypectomy

Abstract

Background/Aims: The risk for colonoscopic postpolypectomy bleeding (PPB) in patients with chronic liver disease (CLD) remains unclear. We determined the incidence and risk factors for colonoscopic PPB in patients with CLD, especially those with liver cirrhosis. Methods: We retrospectively reviewed the medical records of patients with CLD who underwent colonoscopic polypectomy at Seoul National University Hospital between 2011 and 2014. The study endpoints were immediate and delayed PPB. Results: A total of 1,267 consecutive patients with CLD were included in the study. Immediate PPB occurred significantly more often in the Child-Pugh (CP) B or C cirrhosis group (17.5%) than in the CP-A (6.3%) and chronic hepatitis (4.6%) groups (p<0.001). Moreover, the incidence of delayed PPB in the CP-B or C cirrhosis group (4.4%) was significantly higher than that in the CP-A (0.7%) and chronic hepatitis (0.2%) groups (p<0.001). The independent risk factors for immediate PPB were CP-B or C cirrhosis (p=0.011), a platelet count <50,000/μL (p<0.001), 3 or more polyps (p=0.017), endoscopic mucosal resection or submucosal dissection (p<0.001), and polypectomy performed by trainees (p<0.001). The independent risk factors for delayed PPB were CP-B or C cirrhosis (p=0.009), and polyps >10 mm in size (p=0.010). Conclusions: Patients with CP-B or C cirrhosis had an increased risk for bleeding following colonoscopic polypectomy.

Procedure‐related bleeding risk in patients with cirrhosis and severe thrombocytopenia

“…Only a few studies, among those who assessed the risk of bleeding in relation to platelet count, found that thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, 11,33 dental extractions, 13,14 percutaneous ablation of liver tumours 16,46 and endoscopic polypectomy. 15 Noteworthy, none of the prospective studies included in this review highlighted a significant correlation between postprocedural haemorrhagic rate and platelet count. 9,[21][22][23] Despite the above limitations, that would require the conduction of prospective studies properly designed to evaluate the bleeding risk in patients with chronic liver disease undergoing invasive procedures, according to platelet count, the available literature highlighted that severe thrombocytopenia is one of the most frequent issues to exclude cirrhotic patients to invasive procedures, which could be, in some cases, life-saving, such as percutaneous radio-frequency ablation in malignant lesions.…”

“…Some studies evaluated the overall risk of bleeding in cirrhotic patients submitted to different procedures and the association with platelet count and/or coagulopathy. 9,13,15,23 In the open-label, intention-to-treat trial of De Pietri et al 9 cirrhosis and significant coagulopathy (defined as INR > 1.8 and/or platelet count < 50 × 10 9 /L) did not expose to an increased procedure-related bleeding risk, regardless of the procedure (i.e. high-or low-risk procedures), although the cohort included was small (i.e.…”

“…In this case, the only parameter associated with the risk of bleeding was the number of invasive procedures sequentially performed in each single patient: 3 events following 598 single procedures (bleeding rate: 0.5%) and 7 events following multiple procedures (1.5%). 15 Also, in the randomized controlled trial of Vuyyuru et al 23 no bleeding complications occurred following 58 procedures in cirrhotic patients with platelet count < 50 × 10 9 /L, whereas in the prospective multicentre study of Shah et al, 13 in which none of the patients received peri-procedural correction of abnormal coagulation parameters, the occurrence of clinically significant bleeding following high-risk procedures (i.e. cholecystectomy, splenectomy, chemoembolization, central vein cannulation, percutaneous liver biopsy and endoscopic polypectomy) tended to be greater in patients with significant coagulopathy (defined as INR ≥ 1.5 and/or platelet count ≤ 50 × 10 9 /L) as compared to patients without significant coagulopathy (3 vs 0, P = .061), although it was not possible to single out the role played by thrombocytopenia alone on the bleeding risk in this study.…”

“…Since in the Position Paper AISF/SIMI selection criteria were not specified, we assumed they were the same ones we applied in our literature search. Therefore, the 15 studies, which met the inclusion criteria, 9‐23 were analysed together with those identified by the working group AISF/SIMI 24‐68 …”

“…All the studies identified were retrospective and potentially biased by the heterogeneity of the investigated population including both cirrhotic and noncirrhotic patients 15,42,43 . Only the study by Soh et al 15 identified a correlation between post‐procedural bleeding and platelet count: while the overall haemorrhagic rate was 7.5%, in patients with platelets <50 × 10 9 /L, the immediate post‐procedural bleeding rate was 27.5% with a relative risk of about 6.…”