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

Kirles Bishay^{1

2}, Yibing Ruan^{3

4}, Alan N Barkun⁵, Yen-I Chen⁵, Andrew Singh⁶, Lawrence Hookey⁷, Naveen Arya⁸, Natalia Causada Calo⁹, Samir C Grover^{10

11}, Peter D Siersema¹², Nirav Thosani¹³, Saeed Darvish-Kazem¹⁴, Deborah Siegal^{15

16}, Sydney Bass², Martin Cole², Yang Lei², Suqing Li², Rachid Mohamed², Christian Turbide², Millie Chau², Megan Howarth², Shane Cartwright², Hannah F Koury², Tamim Nashad², Zhao Wu Meng^{1

2}, Alejandra Tepox-Padrón², Ahmed Kayal^{2

17}, Emmanuel González-Moreno², Darren R Brenner^{3

4}, Zachary L Smith¹⁸, Rajesh N Keswani¹⁹, B Joseph Elmunzer²⁰, Sachin Wani²¹, Ronald J Bridges², Robert J Hilsden^{1

2}, Steven J Heitman^{1

2}, Nauzer Forbes^{1

2}

Affiliations

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 .

PMID: 39495582
DOI: 10.14309/ajg.0000000000002946

Multicenter Study

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

Kirles Bishay et al. Am J Gastroenterol. 2024.

. 2024 Nov 1;119(11):2317-2325.

doi: 10.14309/ajg.0000000000002946. Epub 2024 Jul 5.

Authors

Affiliations

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 .

PMID: 39495582
DOI: 10.14309/ajg.0000000000002946

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. P2Y 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y 12 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.

Trial registration: ClinicalTrials.gov NCT05929404.

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References

1. Chandrasekhara V, Khashab MA, Muthusamy VR, et al. Adverse events associated with ERCP. Gastrointest Endosc 2017;85(1):32–47.
1. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335(13):909–18.
1. Huang RJ, Barakat MT, Girotra M, et al. Unplanned hospital encounters after endoscopic retrograde cholangiopancreatography in 3 large North American States. Gastroenterology 2019;156(1):119–29.e3.
1. Ferreira LE, Baron TH. Post-sphincterotomy bleeding: Who, what, when, and how. Am J Gastroenterol 2007;102(12):2850–8.
1. Freeman ML. Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography. Curr Gastroenterol Rep 2003;5(2):145–53.

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NB Hershfield Chair in Therapeutic Endoscopy, University of Calgary, Pentax Medical Canada

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

Affiliations

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

Authors

Affiliations

Abstract

References

Publication types

MeSH terms

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Medical