Introduction

Anti-thrombotic (AT) drugs commonly prescribed in cardiovascular disease are considered a recognised risk factor for upper gastro intestinal bleeding (UGIB). However, few studies have evaluated their effect on endoscopic outcomes in patients admitted for UGIB, and have concluded that the results remain controversial.

Aims & Methods

Aims: Evaluate the effect of AT use on endoscopic outcomes in patients admitted for UGIB.
Methods: This is a prospective monocentric cross-sectional study of 332 patients conducted between June 2020 and August 2021.We considered as users of AT drugs all patients on antiplatelet agents (low-dose aspirin, thienopyrimidines) and/or anticoagulants (vitamin K antagonists, direct-acting anticoagulants, heparin).

Results

The average age was 59+/−16.7 years. Our series was characterised by a clear male predominance of 77.1%.63 patients (19%) were taking AT drugs (41 antiplatelet, 39 anticoagulant).The two groups differed in age (68 vs 57; p<0.001), comorbidities (75.8% vs 16.7%; p<0.001), however there was no statistically significant difference in active bleeding at endoscopy (12.7%vs 16.8%; p=0.425), and the need for endoscopic haemostasis (7.9%vs 16%; p=0.1).In multivariate analysis and adjusting for age, sex, comorbidities, presence of active bleeding and use of antithrombotics, only the presence of active bleeding could predict the need for endoscopic haemostasis. Indeed, the presence of active bleeding at the time of endoscopy multiplies by 26 the risk of recourse to endoscopic haemostasis (OR: 26, CI: 12.9–62.15, p<0.001), whereas the use of AT drugs does not influence the need for endoscopic haemostasis (OR: 0.386, CI: 0.105- 1.42, p=0.154).

Conclusion

Older patients using AT admitted for UGIB do not appear to have an increased risk of active bleeding at endoscopy or needing endoscopic haemostasis.

Introduction

Upper gastrointestinal bleeding (UGIB) is the most common diagnostic and therapeutic emergency in hepato-gastroenterology, potentially life-threatening and requiring multidisciplinary management.
Anti-thrombotic (AT) drugs commonly prescribed for cardiovascular diseases are considered a recognised risk factor for UGIB. However, few studies have evaluated their effect on endoscopic outcomes in patients admitted for UGIB, and have concluded that the results remain controversial.

Aims & Methods

Aims: Evaluate the effect of AT use on endoscopic outcomes in patients admitted for UGIB.
Methods: This is a prospective monocentric cross-sectional study of 332 patients conducted between June 2020 and August 2021.We considered as users of AT drugs all patients on antiplatelet agents (low-dose aspirin, thienopyrimidines) and/or anticoagulants (vitamin K antagonists, direct-acting anticoagulants, heparin).

Results

The average age was 59+/−16.7 years. Our series was characterised by a clear male predominance of 77.1%.63 patients (19%) were taking AT drugs (41 antiplatelet, 39 anticoagulant).The two groups differed in age (68 vs 57; p<0.001), comorbidities (75.8% vs 16.7%; p<0.001), however there was no statistically significant difference in active bleeding at endoscopy (12.7%vs 16.8%; p=0.425), and the need for endoscopic haemostasis (7.9%vs 16%; p=0.1).In multivariate analysis and adjusting for age, sex, comorbidities, presence of active bleeding and use of antithrombotics, only the presence of active bleeding could predict the need for endoscopic haemostasis. Indeed, the presence of active bleeding at the time of endoscopy multiplies by 26 the risk of recourse to endoscopic haemostasis (OR: 26, CI: 12.9–62.15, p<0.001), whereas the use of AT drugs does not influence the need for endoscopic haemostasis (OR: 0.386, CI: 0.105- 1.42, p=0.154)

Conclusion

Older patients using AT admitted for UGIB do not appear to have an increased risk of active bleeding at endoscopy or needing endoscopic haemostasis.

Clinical Case Summary

Clinical presentation: A 45-year-old male with a history of recurrent episodes of variceal bleeding due to decompensated liver cirrhosis of unknown etiology and esophageal variceal ligation (EVL) elsewhere two weeks ago presented to our emergency department with large volume hematemesis and hemodynamic instability.
Therapeutic approach: Immediate resuscitation was offered, with airway intubation and management as per massive bleeding protocol. Somatostatin and antibiotics iv were also administered. Urgent upper gastrointestinal endoscopy was performed once the patient was stabilized, and it revealed active bleeding from a deep, large ulcer at a large esophageal varix just above the gastroesophageal junction. EVL was unsuccessfully attempted twice, due to the disproportionately big size of the variceal ulcer compared to the band device. Emergency transjugular intrahepatic portosystemic shunt (TIPS) and dedicated esophageal stents for varices were not available at the time in our Unit. A decision was made to use an over-the scope clip (OTSC®) as a rescue therapy in this life-threatening condition. OTSC® was successfully applied on variceal ulcer bed and hemostasis was immediately achieved. The patient remained hemodynamically stable after the procedure without clinical signs of further bleeding. He underwent a second endoscopy 48 hours later without endoscopic signs of bleeding or clinically relevant lumen stenosis, while OTSC® was in place. TIPS was planned for the following day.
Discussion: We report the successful use of an over-the-scope clip as a rescue therapy for a patient with massive esophageal variceal bleeding in the absence of established rescue therapies. No clip-related adverse events occurred at the post-treatment period.

References

3 endoscopic images of active variceal bleeding and over-the scope clip placement.