Incidence, Predictors, and Outcomes of Clinically Significant Post-Endoscopic Retrograde Cholangiopancreatography Bleeding: A Contemporary Multicenter Study-Reference-Cited by-同舟云学术

Incidence, Predictors, and Outcomes of Clinically Significant Post-Endoscopic Retrograde Cholangiopancreatography Bleeding: A Contemporary Multicenter Study

Published:2024-07-05 Issue: Volume: Page:
ISSN:0002-9270
Container-title:American Journal of Gastroenterology
language:en
Short-container-title:Am J Gastroenterol

Author:

Bishay Kirles¹²,Ruan Yibing³⁴,Barkun Alan N.⁵,Chen Yen-I⁵^ORCID,Singh Andrew⁶,Hookey Lawrence⁷,Arya Naveen⁸,Calo Natalia Causada⁹^ORCID,Grover Samir C.¹⁰¹¹^ORCID,Siersema Peter D.¹²,Thosani Nirav¹³^ORCID,Darvish-Kazem Saeed¹⁴,Siegal Deborah¹⁵¹⁶^ORCID,Bass Sydney²,Cole Martin²,Lei Yang²^ORCID,Li Suqing²,Mohamed Rachid²,Turbide Christian²,Chau Millie²,Howarth Megan²,Cartwright Shane²,Koury Hannah F.²,Nashad Tamim²,Meng Zhao Wu¹²^ORCID,Tepox-Padrón Alejandra²^ORCID,Kayal Ahmed²¹⁷^ORCID,González-Moreno Emmanuel²^ORCID,Brenner Darren R.³⁴^ORCID,Smith Zachary L.¹⁸^ORCID,Keswani Rajesh N.¹⁹,Elmunzer B. Joseph²⁰,Wani Sachin²¹,Bridges Ronald J.²,Hilsden Robert J.¹²^ORCID,Heitman Steven J.¹²,Forbes Nauzer¹²^ORCID

Affiliation:

1. Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;

2. Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada;

3. Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;

4. Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada;

5. Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada;

6. Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of British Columbia, Victoria, British Columbia, Canada;

7. Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada;

8. Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada;

9. Division of Gastroenterology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada;

10. Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada;

11. Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada;

12. Department of Gastroenterology and Hepatology, Erasmus MC–University Medical Center, Rotterdam, the Netherlands;

13. Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA;

14. Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada;

15. Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada;

16. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada;

17. Department of Medicine, Faculty of Medicine–Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia;

18. Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA;

19. Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA;

20. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA;

21. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Abstract

INTRODUCTION: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB. METHODS: We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported. RESULTS: CSPEB occurred after 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring after higher risk interventions (sphincterotomy, sphincteroplasty, precut sphincterotomy, and/or needle-knife access). Patients with CSPEB required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with 3 cases (2.3%) being fatal. P2Y12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After 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 after sphincterotomy (OR 2.32, 1.06–4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75–32.54). DISCUSSION: 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.

Funder

NB Hershfield Chair in Therapeutic Endoscopy, University of Calgary

Pentax Medical Canada

Publisher

Ovid Technologies (Wolters Kluwer Health)

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