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Small bowel ulcer bleeding due to suspected clopidogrel use in a patient with clopidogrel resistance: A case report
Sang Hoon Lee1, Dong Ryeol Ryu2, Sung Joon Lee1
1Division of Gastroenterology, Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon-si 24289, South Korea.
Insights
Clopidogrel resistance can cause gastrointestinal bleeding, particularly small bowel ulcers in elderly patients. Switching to aspirin improved ulcers in a patient with clopidogrel resistance.
Area of Science:
- Gastroenterology
- Cardiology
- Pharmacology
Background:
- Clopidogrel, an antiplatelet medication, is crucial for managing cardiovascular disease and preventing events after stenting.
- However, it increases the risk of gastrointestinal bleeding and approximately 20% of patients exhibit resistance.
- Gastrointestinal bleeding is a significant concern in patients undergoing antiplatelet therapy.
Observation:
- A case report details an 86-year-old male with clopidogrel resistance presenting with small bowel bleeding.
- Upper and lower endoscopies revealed no source of bleeding; however, CT imaging indicated extravasation in the ileum.
- Emergency surgery identified multiple inflamed ulcers in the ileum.
Findings:
- Pathology confirmed simple inflammation in the ileal ulcers.
- The VerifyNow P2Y12 test definitively showed clopidogrel resistance.
- Capsule endoscopy one year after switching to aspirin demonstrated improvement in small bowel ulcers.
Implications:
- Small bowel ulcers due to clopidogrel, though uncommon, are an emerging clinical concern, especially in elderly patients.
- Clopidogrel resistance may contribute to adverse gastrointestinal events.
- Alternative antiplatelet strategies, such as aspirin, may be effective in managing such cases.
Background:
Clopidogrel is a platelet aggregation inhibitor used for the management of cardiovascular disease. While antiplatelet therapy decreases cardiovascular events after successful coronary drug-eluting stenting, it increases the risk of gastrointestinal (GI) bleeding. About 20% of the patients who take clopidogrel exhibit resistance to the drug.
Case Summary:
We report the first case of a small bowel bleeding ulcer in an 86-year-old man with clopidogrel resistance. He had a history of taking clopidogrel due to unstable angina. There was no evidence of bleeding in the stomach, duodenum, or colon through upper and lower GI endoscopies. The abdominal computed tomography showed the extravasation of radiocontrast media at the ileum. Because of unstable vital signs, emergency surgery was performed. Multiple ulcers with inflammation were found in the ileum. The pathologic findings revealed simple inflammation. The VerifyNow P2Y12 test showed clopidogrel resistance. One year after changing to aspirin, capsule endoscopy was performed and the small bowel ulcers were improved.
Conclusion:
Small bowel ulcers and bleeding due to clopidogrel are not very common, but the prevalence is expected to increase in older age patients with risk factors despite clopidogrel resistance.
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