Risk of colonoscopic post-polypectomy bleeding in patients on single antiplatelet therapy: systematic review with meta-analysis

Abstract

Background It was not yet fully established whether the use of antiplatelet agents (APAs) is associated with an increased risk of colorectal post-polypectomy bleeding (PPB). Temporarily, discontinuation of APAs could reduce the risk of PPB, but at the same time, it could increase the risk of cardiovascular disease recurrence. This study aimed to assess the PPB risk in patients using APAs compared to patients without APAs or anticoagulant therapy who had undergone colonoscopy with polypectomy. Methods A systematic electronic search of the literature was performed using PubMed/MEDLINE, Scopus, and CENTRAL, to assess the risk of bleeding in patients who do not interrupt single antiplatelet therapy (P2Y12 inhibitors or aspirin) and undergone colonoscopy with polypectomy. Results Of 2417 identified articles, 8 articles (all of them were non-randomized studies of interventions (NRSI); no randomized controlled trials (RCT) were available on this topic) were selected for the meta-analysis, including 1620 patients on antiplatelet therapy and 13,321 controls. Uninterrupted APAs single therapy was associated with an increased risk of PPB compared to the control group (OR 2.31; CI 1.37–3.91). Patients on P2Y12i single therapy had a higher risk of both immediate (OR 4.43; CI 1.40–14.00) and delayed PPB (OR 10.80; CI 4.63–25.16) compared to the control group, while patients on aspirin single therapy may have a little to no difference increase in the number of both immediate and delayed PPB events. Conclusions Uninterrupted single antiplatelet therapy may increase the risk of PPB, but the evidence is very uncertain. The risk may be higher in delayed PPB. However, in deciding to discontinue APAs before colonoscopy with polypectomy, the potential higher risk of major adverse cardiovascular events should always be assessed.

The Effectiveness of Prophylactic Epinephrine Compared to No Prophylaxis for Postpolypectomy Bleeding in Endoscopic Colorectal Surgery: A Systematic Review and Meta-Analysis

“…Our study aligns with previous research in terms of the effectiveness of prophylactic epinephrine in reducing early postpolypectomy bleeding [ 23 , 24 ]. However, it diverges regarding delayed bleeding outcomes, where our findings indicate a lack of significant impact, contrasting with previous reports [ 19 , 21 , 22 ].…”

“…In our cohort, epinephrine administration significantly reduced early or immediate postpolypectomy bleeding to 3%, in contrast to 8.64% in the no-prophylaxis group. This intervention did not show any effect on the incidence of delayed bleeding, which was 0.85%, exceeding the range of 0.14% to 0.74% noted in previous studies [ 19 , 21 , 22 ]. These findings offer nuanced insights into the differential impacts of prophylactic strategies during various postpolypectomy phases.…”

Safe, efficient, and effective screening colonoscopy

“…Direct oral anticoagulants (DOACs) including apixaban, dabigatran and rivaroxaban are typically held for two days on average, longer if the patient has renal insufficiency while warfarin and the APs including clopidogrel and ticagrelor are held for five days. Current research continues to support these guidelines [9,10 ▪ ]. However, recent data reveals a significant rate of postpolypectomy bleeding (PPB) even when these guidelines are followed for both APs and anticoagulants estimated to be between 1–2% so patients should be advised to monitor for bleeding per rectum after careful resumption of these medications [11 ▪ ].…”

The connection between diverticulosis and colonic superficial neoplastic lesions in patients who underwent screening colonoscopy

“…These advances are mainly imputable to colonoscopy screening programs, early diagnosis, and improvement of medical and surgical therapies. Also important is the continuous improvement of endoscopic techniques for the detection and resection of polyps, despite some complications such as perforation and bleeding, the latter, especially in some patients on anticoagulant and antiplatelet therapy [27].…”