Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, California, USA; Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA.
Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA.
Gastrointest Endosc. 2018 Apr;87(4):1106-1113. doi: 10.1016/j.gie.2017.11.024. Epub 2017 Dec 6.
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.
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.
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).
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.
在需要抗凝和抗血小板药物的患者中，平衡血栓栓塞和息肉切除后出血的风险具有挑战性。我们调查了抗凝治疗后息肉切除后出血的发生率和危险因素，包括肝素桥接和其他抗血栓治疗。
我们在 2004 年至 2012 年期间在 2 家三级医疗中心进行了回顾性队列和病例对照研究。病例包括接受抗血栓治疗并在息肉切除后出现血便的男性患者。非出血对照与病例按抗血栓类型、研究地点、息肉切除技术和手术年份 3:1 匹配。我们的结局是息肉切除后出血的发生率和危险因素。
有 59 例病例和 174 例匹配对照。桥接抗凝治疗后出血的发生率为 14.9%。这明显高于抗凝治疗总体出血率 1.19%（95%置信区间，0.91%-1.54%）（59/4923）。我们发现服用华法林（0.66%）、氯吡格雷（0.84%）和阿司匹林（0.92%）的患者出血率相似较低。出血患者的息肉较大（13.9 毫米比 7.3 毫米；P<.001），息肉≥2 厘米的患者更多（41%比 10%；P<.001）。在息肉切除后 1 周内重新开始抗血栓治疗（比值比[OR]4.50；P<.001）、有息肉≥2 厘米（OR 5.94；P<.001）、右侧烧灼（OR 2.61；P=.004）和有多发性大息肉（OR 2.92；P=.001）的患者出血风险增加。在服用华法林的患者中，桥接抗凝治疗是息肉切除后出血的独立危险因素（OR 12.27；P=.0001）。
我们得出的结论是，与单独服用华法林的患者相比，桥接抗凝治疗与息肉切除后出血的高发生率相关，并且是出血的独立危险因素。对于出血风险较高的患者，应考虑使用桥接抗凝治疗的更高阈值。
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