The safety of endoscopic sphincterotomy in patients receiving antiplatelet agents – a case–control study

Abstract

SUMMARY ObjectiveTo determine whether antiplatelet agents are associated with endoscopic sphincterotomy-related haemorrhage as few well-controlled data exist on this controversial issue. MethodsA case-control study in a tertiary care setting included cases with bleeding following endoscopic sphincterotomy, matched with 2-3 controls selected according to age AE 15 years, sex, and procedural date AE 2 years. Cases and controls were compared for possible risk factors of postendoscopic sphincterotomy bleeding (presence of a coagulopathy and cholangitis). The main outcome measurement was the association between the use of antiplatelet medications and postendoscopic sphincterotomy bleeding after adjustment for possible confounding. ResultsThe 40 cases [mean age 68 AE 17 (s.d.) years, 50% female] and 86 controls [68 AE 16 years, 50% female] were comparable except for differences noted in International Normalized Ratio (INR) (>2 in four cases vs. two controls), and pre-endoscopic sphincterotomy cholangitis (45% vs. 20%). Amongst cases, 13% were on aspirin and 3% on clopidogrel; 17% of controls took aspirin, and 4% a non-steroidal anti-inflammatory drug. 53% of cases bled immediately; the remainder haemorrhaged at 2 AE 3 days. After adjustment for an elevated INR and cholangitis, exposure to antiplatelet agents was not significantly associated with procedure-related bleeding (odds ratio ¼ 0.41, 95% CI [ 0.13; 1.31]). ConclusionThis case-control study provides controlled data suggesting that antiplatelet agents do not significantly increase the risk of clinicallyimportant bleeding related to endoscopic sphincterotomy. The low prevalences of non-steroidal anti-inflammatory drugs and clopidogrel use limit any definite conclusion on their elective use before endoscopic sphincterotomy.

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

“…In addition to these studies, a retrospective study compared 40 patients with post-sphincterotomy bleeding vs 86 matched controls who had no post-sphincterotomy bleeding; similar proportions of patients taking APA were found among both groups of patients (13% aspirin and 3% clopidogrel vs 17% aspirin and 0% clopidogrel in cases vs controls, respectively). 140 Endoscopic sphincterotomy followed by large balloon dilation is increasingly undertaken for large biliary stone extraction; haemorrhage has been reported in 0-8.6% of patients. 141 A single series was identified that included five patients taking aspirin at the time of endoscopic sphincterotomy followed by large balloon dilation; none of them presented with significant bleeding.…”

Biliary-pancreatic endoscopic and surgical procedures in patients under dual antiplatelet therapy: A single-center study

“…14 In contrast to the increased risk of bleeding in the setting of transbronchial biopsies under dual antiplatelet therapy as shown by Ernst et al, 11 in our retrospective analysis, ES was performed safely in nine consecutive patients on uninterrupted combined antiplatelet therapy. Neither endoscopically relevant immediate nor clinically significant delayed bleeding was observed.…”

Current Practices in the Management of Antithrombotic Therapy During the Periendoscopic Period for Patients With Cardiovascular Disease

“…25) Conversely, Hui, et al evaluated the safety of EST with aspirin continuation in a retrospective study. 26) They concluded that aspirin continuation increased the risk of postoperative bleeding even when there was a discontinuation period of one week before EST. Recently, Hamada, et al analyzed a large number of EST and EPBD cases from a nationwide administrative database in Japan and concluded that both procedures could be safely performed in patients receiving antiplatelet agents, although post-procedural bleeding risk might be increased in patients receiving anticoagulants.…”