Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications

David Lin; Roy M Soetikno; Kenneth McQuaid; Chi Pham; Gilbert Doan; Shanshan Mou; Amandeep K Shergill; Ma Somsouk; Robert V Rouse; Tonya Kaltenbach

doi:10.1016/j.gie.2017.11.024

Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications

Gastrointest Endosc. 2018 Apr;87(4):1106-1113. doi: 10.1016/j.gie.2017.11.024. Epub 2017 Dec 6.

Authors

Affiliations

¹ Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, California, USA; Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA.
² Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA.
³ Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA.
⁴ Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
⁵ Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA.
⁶ Department of Pathology, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA.
⁷ Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA; Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA.

PMID: 29208464
DOI: 10.1016/j.gie.2017.11.024

Abstract

Background and aims: Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy.

Methods: We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding.

Results: There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001).

Conclusion: We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.

MeSH terms

Aged
Anticoagulants / therapeutic use
Aspirin / therapeutic use
Case-Control Studies
Clopidogrel
Colonic Polyps / pathology
Colonic Polyps / surgery*
Colonoscopy
Colorectal Neoplasms / pathology
Colorectal Neoplasms / surgery*
Female
Gastrointestinal Hemorrhage / epidemiology*
Gastrointestinal Hemorrhage / etiology
Heparin, Low-Molecular-Weight / therapeutic use
Humans
Incidence
Male
Middle Aged
Platelet Aggregation Inhibitors / therapeutic use*
Postoperative Hemorrhage / epidemiology*
Postoperative Hemorrhage / etiology
Retrospective Studies
Risk Factors
Thromboembolism / prevention & control
Ticlopidine / analogs & derivatives
Ticlopidine / therapeutic use
Time Factors
Warfarin / therapeutic use

Substances

Anticoagulants
Heparin, Low-Molecular-Weight
Platelet Aggregation Inhibitors
Warfarin
Clopidogrel
Ticlopidine
Aspirin