Original article
Clinical endoscopy
Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications

https://doi.org/10.1016/j.gie.2017.11.024Get rights and content

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.

Section snippets

Study design

The study was conducted at 2 VA hospitals with similar endoscopic practices, VA Palo Alto and VA San Francisco. All procedures were performed or supervised by 1 of 24 staff endoscopists from January 2004 to June 2012. The study was conducted in 2 parts. The first was a retrospective cohort study to assess the primary endpoint and the incidence of postpolypectomy bleeding on various antithrombotics. The second was a matched case control study to examine the secondary endpoint, risk factors for

Bleeding incidence

We identified 20,374 cases with polypectomy. Approximately a quarter of these patients were on warfarin, low molecular weight heparin, clopidogrel, or aspirin. Among cases on antithrombotics, 12.5% were on warfarin.

We found a significantly higher rate of postpolypectomy bleeding in patients on anticoagulation bridge therapy at 14.9% (13/87) (95% CI, 8.20%-24.4%). This was in comparison to patients taking antithrombotics at 1.19% (59/4923) (95% CI, 0.91%-1.54%) (Table 1). The bleeding incidence

Discussion

We found that the risk of postpolypectomy bleeding in patients on bridge anticoagulation was significantly higher than that of patients on warfarin alone. Moreover, this was an independent risk factor for postpolypectomy bleeding, conferring a 10-fold higher risk of bleeding. We demonstrated that the incidence of bleeding for patients on bridge anticoagulation approached 1 in 7 patients undergoing polypectomy. This is in stark contrast to the overall low incidence of postpolypectomy bleeding in

Acknowledgments

The authors thank Kristin Frazier for helping to obtain the request for database query.

References (21)

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

See CME section: p. 1121.

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