Endoscopic biliary sphincterotomy in patients under antithromboembolic therapy

Abstract

Background Endoscopic sphincterotomy (EST) carries several risks (e. g., pancreatitis and bleeding). The risk of bleeding is increased in patients with a compromised coagulation system, often due to antithromboembolic therapy. Recent guidelines caution to perform endoscopic procedures that carry a high risk of bleeding in these patients. However, data to support current recommendations are scarce, and EST frequently has to be performed as an emergency procedure. Therefore, it was the aim of our retrospective study to evaluate the rate of procedural bleeding in patients undergoing EST in our endoscopy unit while on antithromboembolic therapy.

Methods Between March 2005 and August 2015, 1798 consecutive patients underwent EST at HELIOS Hospital in Pforzheim, Germany. Concomitant therapy with anticoagulants and/or antiplatelet agents was noted, and bleeding following sphincterotomy was recorded.

Results We observed 54 bleeding events in 1482 patients (3.6 %) without and 20 events in 316 patients (6.3 %) with antithromboembolic therapy. Bleeding was recorded in 7 out of 123 patients (5.7 %) taking aspirin, in one out of 34 patients (2.9 %) taking clopidogrel, and in 12 out of 209 patients under heparin (5.7 %). Compared to controls, no statistically significant increase in the bleeding rate was seen. However, we observed an association between a lower physical health score and increased bleeding rate. If precut was necessary for biliary tract access, the bleeding rate increased significantly (p < 0.01).

Conclusion Bleeding following EST is neither increased in patients taking clopidogrel and/or aspirin or heparin and rarely requires transfusion of packed red blood cells nor does it lead to an increased mortality. However, bleeding following EST seems to occur more frequently in patients with a compromised health status or following precut of the papilla.

Zusammenfassung

Hintergrund Endoskopische Sphinkterotomie (EST) ist nicht selten mit eingriffsbedingten Komplikationen assoziiert, wie z. B. Pankreatitis und Blutung. Das Blutungsrisiko ist erhöht bei Patienten mit einem kompromittierten Koagulationsystem. Dabei handelt es sich meistens um Patienten unter antithromboembolischer Therapie. Aktuelle Leitlinien raten in diesem Fall von der Durchführung endoskopischer Prozeduren mit erhöhtem Blutungsrisiko jedoch ab. Allerdings basieren aktuelle Leitlinien überwiegend auf Expertenmeinungen. Darüber hinaus wird die EST oft als Notfall-Eingriff durchgeführt. Das Ziel dieser retrospektiven Arbeit war, das Blutungsrisiko bei Patienten unter antithromboembolischer Therapie, die sich eine EST in unserer Abteilung unterzogen haben, zu evaluieren.

Methodik Zwischen März 2005 und August 2015 wurde in unserer Klinik eine EST bei 1,798 konsekutiven Patienten durchgeführt. Es wurden Therapien mit Antikoagulanzien beziehungsweise Thrombozytenaggregationshemmern dokumentiert und Blutungen nach endoskopischer Sphinktertomie erfasst.

Ergebnisse Wir dokumentierten 54 Blutungsepisoden bei 1,482 Patienten (3,6 %) ohne und 20 Blutungsepisoden bei 316 Patienten mit antithromboembolischer Therapie. Es traten bei 7 von insgesamt 123 Patienten (5,7 %) mit Aspirin-Einnahme, einem Patienten von 34 Patienten (2,9 %) unter Clopidogrel-Therapie und bei 12 von insgesamt 209 Patienten unter Heparin (5,7 %) Blutungen auf. Patienten unter antithromboembolischer Therapie wiesen bezüglich Blutungsrate im Vergleich mit der Kontrollgruppe ohne antithromboembolische Therapie keinen signifikanten Unterschied auf. Wir beobachteten eine Assoziation zwischen einem reduzierten klinischen Status (ASA) und einem erhöhten Blutungsrisiko. Darüber hinaus erhöhte eine Vorschneide-Pappilotomie das Blutungsrisiko signifikant (p < 0.01).

Schlussfolgerung Die Einnahme von antithromboembolischer Medikation ist nicht mit einem erhöhten Blutungsrisiko nach endoskopischer Sphinkterotomie assoziiert, bedarf selten einer Bluttransfusion und weist keine erhöhte Mortalität auf. Dennoch wurden Blutungen nach endoskopischer Papillotomie bei Patienten mit einem reduzierten klinischen Status sowie nach Vorschneide-Papillotomie häufiger beobachtet.

Schlüsselwörter

Endoskopische Sphinkterotomie - Blutung - Thrombozytenaggregationshemmer - Antikoagulation

Key words

endoscopic sphincterotomy - procedural bleeding - antiplatelet therapy - anticoagulation

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