Incidence, Predictors, and Outcomes of Clinically Significant Post-ERCP Bleeding: a Contemporary Multi-center Study

Kirles Bishay; Yibing Ruan; Alan N Barkun; Yen-I Chen; Andrew Singh; Lawrence Hookey; Naveen Arya; Natalia Causada Calo; Samir C Grover; Peter D Siersema; Nirav Thosani; Saeed Darvish-Kazem; Deborah Siegal; Sydney Bass; Martin Cole; Yang Lei; Suqing Li; Rachid Mohamed; Christian Turbide; Millie Chau; Megan Howarth; Shane Cartwright; Hannah F Koury; Tamim Nashad; Zhao Wu Meng; Alejandra Tepox-Padrón; Ahmed Kayal; Emmanuel González-Moreno; Darren R Brenner; Zachary L Smith; Rajesh N Keswani; B Joseph Elmunzer; Sachin Wani; Ronald J Bridges; Robert J Hilsden; Steven J Heitman; Nauzer Forbes

doi:10.14309/ajg.0000000000002946

Incidence, Predictors, and Outcomes of Clinically Significant Post-ERCP Bleeding: a Contemporary Multi-center Study

Am J Gastroenterol. 2024 Jul 5. doi: 10.14309/ajg.0000000000002946. Online ahead of print.

Authors

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, AB, Canada.
² Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
³ Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
⁴ Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, AB, Canada.
⁵ Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada.
⁶ Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of British Columbia, Victoria, BC, Canada.
⁷ Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.
⁸ Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, ON, Canada.
⁹ Division of Gastroenterology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
¹⁰ Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
¹¹ Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, 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, ON, Canada.
¹⁵ Division of Hematology Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada.
¹⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, 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, WI, USA.
¹⁹ Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
²⁰ Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA.
²¹ Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.

PMID: 38976522
DOI: 10.14309/ajg.0000000000002946

Abstract

Background aims: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors for and outcomes following CSPEB.

Methods: We analyzed multi-center prospective ERCP data between 2018-2023 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in: hemoglobin drop ≥20 g/L or transfusion and/or endoscopy to evaluate suspected bleeding, and/or unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was employed. P-values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported.

Results: CSPEB occurred following 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring following higher-risk interventions (sphincterotomy, sphincteroplasty, pre-cut sphincterotomy, and/or needle-knife access). CSPEB patients required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with three cases (2.3%) being fatal. P2Y12 inhibitors were held for a median of 4 days (IQR 4) prior to higher-risk ERCP. Following higher-risk interventions, P2Y12 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 post sphincterotomy (OR 2.32, 1.06-4.60), but not post sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days following CSPEB (OR 12.71, 4.75-32.54).

Conclusions: 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.

Grants and funding

NB Hershfield Chair in Therapeutic Endoscopy, University of Calgary