P1517 - Comparison of Post-ERCP GI Bleeding Between Patients on Dual Anti-platelet Therapy and Aspirin Alone: A Nationwide Population-based Cohort Study

Aakash Desai, MD¹, Yuhan Fu, DO¹, Tarun Rustagi, MD², Nisheet Waghray, MD¹, Dalbir S. Sandhu, MD^3
1MetroHealth Medical Center, Cleveland, OH; ²University of New Mexico, Albuquerque, NM; ³Cleveland Clinic, Cleveland, OH

Introduction: Patients on dual anti-platelet therapy (DaPT) are asked to stop P2Y12 receptor blockers and continue aspirin when feasible for high-risk endoscopic procedures. Data on the benefit of discontinuation of these agents on the risk of GI bleeding is limited. The primary aim of our study was to compare the risk and severity of clinically significant GI bleeding after urgent ERCP in patients on aspirin and DaPT.

Methods: We performed a retrospective analysis in the IBM Explorys database (1999-2021), a pooled, national, de-identified clinical database of over 74 million unique patients from 300 hospitals across the United States. Patient populations were identified using SNOMED and ICD codes. The DaPT cohort included patients with myocardial infarction or endovascular stent placement who were on aspirin and clopidogrel; and subsequently developed cholangitis or biliary obstruction within 1 year and had ERCP within 3 days. Clinically significant GI bleeding was defined as needing esophagogastroduodenoscopy (EGD) within 7 days of ERCP. Control cohort had similar inclusion criteria except patients were on aspirin alone. We excluded patients with any other etiology of GI bleeding from both cohorts. Clinical outcomes assessed included early GI bleeding (< 2 days), late GI bleeding (2-7 days), cardiac arrest within 30 days, embolization, blood transfusion and repeat EGD. Odds ratios with 95% confidence intervals (CI) was performed to compare the risk of each clinical outcome between the cohorts.

Results: Urgent ERCP was performed in 1710 patients on DaPT; 37.4% had sphincterotomy, 36.8% had biliary stent and 12.2% had combination therapy. DaPT cohort group had higher risk of cardiac arrest (OR 2.3, 95% CI 1.54-3.42), embolization (OR 2.13, 95% CI 1.07-4.21) and blood transfusion (OR 2.29, 95% CI 1.63-3.21), but no increased risk for early or late GI bleed (Figure 1). Patients who had sphincterotomy (OR 3.37, 95% CI 2.03-5.58) and combination therapy (OR 2.01, 95% CI 1.00-4.02) had a higher risk of late GI bleed compared to control cohort (Table 1).

Discussion: Patients on DaPT had a higher risk of severe GI bleeding compared to patients on aspirin alone. Additionally, our findings suggest sphincterotomy should be avoided in patients on DaPT when P2Y12 receptor blockers cannot be discontinued.


Figure: Odds ratios with 95% confidence intervals for outcomes in patients undergoing urgent ERCP on DaPT compared to aspirin alone

Outcome	n	Percentage	OR	CI
Sphincterotomy	640
Early GI bleed	40	6.25%	0.98	0.70 - 1.37
Late GI bleed	20	3.13%	3.37	2.03 - 5.58
Blood transfusion	20	3.13%	1.67	1.03 - 2.69
Stent	630
Early GI bleed	40	6.35%	0.74	0.53 - 1.04
Late GI bleed	10	1.59%	1.09	0.56 - 2.12
Blood transfusion	30	4.76%	1.6	1.07 - 2.38
Combination therapy	210
Early GI bleed	10	4.76%	0.59	0.30 - 1.13
Late GI bleed	10	4.76%	2.01	1 - 4.02
Blood transfusion	10	4.76%	1.47	0.74 - 2.89

Table: Outcomes of ERCP in patients on DaPT based on the type of intervention performed. Odds ratio (OR) with 95% confidence interval (CI) were calculated to compare the risk of each outcome to patients on aspirin alone.


Disclosures:
Aakash Desai indicated no relevant financial relationships.
Yuhan Fu indicated no relevant financial relationships.
Tarun Rustagi indicated no relevant financial relationships.
Nisheet Waghray indicated no relevant financial relationships.
Dalbir Sandhu indicated no relevant financial relationships.


Aakash Desai, MD¹, Yuhan Fu, DO¹, Tarun Rustagi, MD², Nisheet Waghray, MD¹, Dalbir S. Sandhu, MD³. P1517 - Comparison of Post-ERCP GI Bleeding Between Patients on Dual Anti-platelet Therapy and Aspirin Alone: A Nationwide Population-based Cohort Study, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.