Major gastrointestinal bleeding and antithrombotics: Characteristics and management

Abstract

BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic. AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events. METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified. RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations ( P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use ( P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents. CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).

Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis

“…The number of patients who needed endoscopic interventions was significantly lower in patients with anticoagulant drug use than those without it (with anticoagulant drugs: 23.9% [28/117]; without anticoagulant drugs: 33.8% [204/604]; P = 0.040). This result may be because patients treated with anticoagulant drugs such as direct oral anticoagulants and warfarin have been reported to have a higher rate of middle or lower gastrointestinal bleeding, and black stools may reflect more distal bleeding than UGIB 28–30 . Of 489 patients who did not undergo endoscopic hemostatic procedures, middle or lower gastrointestinal bleedings were found more in patients who took anticoagulation drugs (15.7%, 14/89) than in those without them (4.3%, 17/400) ( P < 0.001) (Table S6).…”

“…This result may be because patients treated with anticoagulant drugs such as direct oral anticoagulants and warfarin have been reported to have a higher rate of middle or lower gastrointestinal bleeding, and black stools may reflect more distal bleeding than UGIB. [28][29][30] Of 489 patients who did not undergo endoscopic hemostatic procedures, middle or lower gastrointestinal bleedings were found more in patients who took anticoagulation drugs (15.7%, 14/89) than in those without them (4.3%, 17/400) (P < 0.001) (Table S6). In addition, the number of patients treated for vascular disease, such as gastric antral vascular ectasia, and duodenal diverticulum bleeding, was significantly higher in patients with anticoagulant drug use than in those without it (with anticoagulant drugs: five patients; without anticoagulant drugs: eight patients; P = 0.045).…”

Development and Validation of a Novel 1-year Mortality Risk Score That Includes the Use of Antithrombotic in Patients With Overt Gastrointestinal Bleeding

“…Those with a low score have an excellent prognosis and may be managed conservatively to save resources. As the use of AT is increasing worldwide, as is the risk of AT-associated GIB, 14 incorporating the use of AT is essential in any scoring system intended to predict outcome in GIB.…”

A review on increasing risk for gastrointestinal bleeding associated with dabigatran

“…Although age and dose have been associated with increased GIB due to dabigatran, the majority of the research has various limitations that prevent researchers from completely ruling out the possibility of these interactions in their analyses due to flaws in the methodology used to collect the large data sets. The most likely explanation for this discrepancy is that the inclusion criteria used for each set of data are slightly different [44]. Moreover, most observational studies also failed to account for the use of over-the-counter aspirin, which could skew the results if there were a difference in aspirin use rates between patients taking dabigatran and warfarin.…”