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Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis
Shanker Kundumadam1, Parkpoom Phatharacharukul1, Kathryn Reinhart1
1Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Insights
Bleeding after therapeutic endoscopy in cirrhotic patients is infrequent but serious. Younger age and low hemoglobin predict bleeding, which is linked to higher mortality, especially after endoscopic variceal ligation (EVL).
Area of Science:
- Gastroenterology
- Hepatology
- Interventional Endoscopy
Background:
- Therapeutic endoscopy is crucial for managing cirrhotic patients.
- Concerns exist regarding post-procedural bleeding risk in this population.
Purpose of the Study:
- To investigate the incidence, risk factors, and outcomes of bleeding after specific endoscopic procedures in cirrhotic patients.
- To analyze bleeding post-endoscopic variceal ligation (EVL), colonoscopic polypectomy, and ERCP with sphincterotomy.
Main Methods:
- A cohort study of 857 cirrhotic patients undergoing 1,324 procedures (2012-2014).
- Exclusion of patients with active bleeding at the time of procedure.
- 30-day follow-up for bleeding and 90-day for mortality.
Main Results:
- Low bleeding rates: 2.8% post-EVL, 2.0% post-polypectomy, 3.8% post-sphincterotomy.
- Predictors of bleeding included younger age, lower hemoglobin, infection, and MELD-Na score (for EVL).
- Bleeding was associated with significant 90-day mortality (29% post-EVL, 14% post-polypectomy).
Conclusions:
- Elective therapeutic endoscopy in cirrhotic patients has a low incidence of bleeding.
- Younger age, lower hemoglobin, and specific procedural factors are associated with increased bleeding risk.
- Identifying and managing these risk factors is vital for optimizing patient outcomes and reducing mortality.
Introduction:
Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients.
Methods:
A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality.
Results:
A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics.
Discussion:
In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.
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