S655 Risk of GI Bleeding After Urgent ERCP in Patients on Dual Anti-Platelet Therapy: A Nationwide Population-Based Cohort Study

Introduction: Discontinuation of dual anti-platelet therapy (DaPT) is not always feasible prior to urgent high-risk endoscopic procedures. The primary aim of our study was to assess the risk and severity of clinically significant GI bleeding and its outcomes after urgent ERCP in patients on 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 did not include patients on aspirin or other anti-platelet agents. 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: Patients in DaPT cohort had a higher risk of cardiac arrest (OR 7.74, 95% CI 5.19 - 11.55) and blood transfusion (OR 2.96, 95% CI 2.14 - 4.09) compared to the control cohort, however risk of early GI bleed and late GI bleed was similar (Figure 1). Sub-group analysis showed patients who had sphincterotomy or combination therapy had a higher risk of late GI bleeding and blood transfusion compared to control cohort (Table 1). Sensitivity analysis did not show any difference in GI bleed outcomes with respect to age > 65, gender, thrombocytopenia, CKD stage >= 3, obesity and diabetes mellitus in the sphincterotomy group. Conclusion: Our findings suggest sphincterotomy should be avoided in patients on DaPT when P2Y12 receptor inhibitors cannot be stopped. The need for potential blood transfusion should be discussed with patients during informed consent. The higher risk of cardiac arrest could be related to temporary discontinuation of DaPT, delay in ERCP or underlying cardiovascular comorbidity, however this needs be further evaluated in future studies.Figure 1.: A. Demographics and mean ago of the study population. B. Group comparisons using a post hoc test.Table 1.: Study Methodology Quality Assessment on Newcastle-Ottawa Scale.

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