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Incidence, Predictors, and Outcomes of Clinically Significant Post-ERCP Bleeding: a Contemporary Multi-center Study
Kirles Bishay1,2, Yibing Ruan3,4, Alan N Barkun5
1Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
Insights
Clinically significant post-ERCP bleeding (CSPEB) affects 1.5% of procedures, particularly after higher-risk interventions. Antithrombotic management is crucial to mitigate risks and improve patient outcomes.
Area of Science:
- Gastroenterology
- Interventional Endoscopy
- Hepatology
Background:
- Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is a recognized complication.
- Current estimates of CSPEB risk and associated factors are limited.
Purpose of the Study:
- To identify risk factors for CSPEB.
- To determine the outcomes associated with CSPEB.
- To evaluate the impact of antithrombotic medications on CSPEB risk.
Main Methods:
- Prospective, multi-center analysis of ERCP data from 2018-2023.
- Inclusion of 30-day follow-up for all patients.
- Definition of CSPEB based on specific clinical criteria (hematemesis, melena, hematochezia) and consequences (hemoglobin drop, transfusion, endoscopy, prolonged admission).
- Statistical analysis using Firth logistic regression to identify significant risk factors.
Main Results:
- CSPEB occurred in 1.5% of 8,517 ERCPs, with a higher incidence (2.3%) after high-risk interventions.
- Antithrombotic agents, including P2Y12 inhibitors, warfarin, dabigatran, rivaroxaban, and apixaban, were significantly associated with CSPEB following higher-risk procedures.
- Intraprocedural bleeding during sphincterotomy was also a risk factor.
- CSPEB was associated with increased need for endoscopy, transfusion, and a higher rate of concomitant cardiorespiratory events.
Conclusions:
- The risk of CSPEB associated with antiplatelet therapy may be underestimated.
- Suboptimal management of antithrombotic medications before high-risk ERCP procedures is a concern.
- Optimizing periprocedural antithrombotic management is essential and can serve as a target for quality improvement initiatives.
Background Aims:
Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors for and outcomes following CSPEB.
Methods:
We analyzed multi-center prospective ERCP data between 2018-2023 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in: hemoglobin drop ≥20 g/L or transfusion and/or endoscopy to evaluate suspected bleeding, and/or unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was employed. P-values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported.
Results:
CSPEB occurred following 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring following higher-risk interventions (sphincterotomy, sphincteroplasty, pre-cut sphincterotomy, and/or needle-knife access). CSPEB patients required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with three cases (2.3%) being fatal. P2Y12 inhibitors were held for a median of 4 days (IQR 4) prior to higher-risk ERCP. Following higher-risk interventions, P2Y12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24) and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding post sphincterotomy (OR 2.32, 1.06-4.60), but not post sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days following CSPEB (OR 12.71, 4.75-32.54).
Conclusions:
Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher-risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets.
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