Original article
Clinical endoscopy
Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel

This research was presented in part at the annual meeting of the American Society of Gastrointestinal Endoscopy, Digestive Diseases Week, May 1-5, 2010, New Orleans, LA (Gastrointest Endosc 2010;71:AB114, AB267).
https://doi.org/10.1016/j.gie.2011.03.1258Get rights and content

Background

Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding.

Objective

To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement.

Setting

Large quaternary-care academic medical center.

Patients

A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009.

Interventions

PEG tube placement.

Main Outcome Measurements

GI bleeding.

Results

Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04).

Limitations

Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients.

Conclusions

Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.

Section snippets

Methods

We conducted a retrospective, single-center cohort study that included inpatients at the University of Virginia Hospital, which is a large quaternary-care center. Patients on the neurology and cardiothoracic services who underwent PEG from January 1999 to April 2009 were included. Patients were limited to the neurology and cardiothoracic services because they were more likely to require and be exposed to aspirin and/or clopidogrel before and after PEG. This study was approved by our

Patient characteristics

A total of 1091 patients were reviewed, and 101 patients were excluded. A total of 990 patients (525 men) with a median age of 69.8 years (range 18-95 years) underwent PEG during the 10-year study period and were included in the study (Table 1). PEGs ranged in size and included 24F (91.5%), 20F (8.4%), and 18F (0.1%) tubes. Primary diagnoses associated with these patients who required PEG included cerebrovascular accident (n = 377), intracranial hemorrhage (n = 259), other neurological

Discussion

GI bleeding is a clinically important adverse event after PEG placement. PEG is considered a higher risk procedure that has a reported bleeding rate of 2.5%.2, 3 Because of the effectiveness of aspirin and clopidogrel in the prevention of thrombotic vascular events in cardiovascular and cerebrovascular diseases4, 5, 6, 7, 8 and their critical role after coronary artery stent placement,9 endoscopists are increasingly asked to perform procedures in individuals who are on antiplatelet therapies.

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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