Bleeding Risk Associated with Uninterrupted Clopidogrel Therapy during PEG Tube Placement: Largest Single Center Experience Presidential Poster

Abstract

Purpose: The American Society of Gastrointestinal Endoscopy (ASGE) recommends to hold clopidogrel for 7-10 days prior to percutaneous endoscopic gastrostomy (PEG) tube placement, as PEG placement is considered as high risk procedure carrying an increased risk of bleeding. PEG tube placement has overall bleeding risk about 2.5%; however, the risk of bleeding in setting of uninterrupted clopidogrel therapy is unknown. The aim of this study was to assess the bleeding risk in patients undergoing PEG tube placement on uninterrupted antiplatelet therapy. Methods: We performed a single center retrospective study at the University of Texas-Houston Medical School and reviewed the data on all PEG tube placements done at our institution from January 2009 to December 2011. We collected data regarding demographics, clinical parameters, basic laboratory tests, medical history, endoscopy findings, PEG tube techniques, immediate and late complications, clinical outcomes, and survival data in form of date and cause of death and/or last known follow up. Post PEG bleeding (PPB) was defined as bleeding from the PEG tube tract or hematemesis, melena or drop in hemoglobin requiring blood transfusion from the etiology that can be attributed directly to PEG tube placement. Results: A total of 467 patients underwent PEG tube placement between January 2009 and December 2011. Of 467, 43 (9%) of the patients were on clopidogrel therapy secondary to cardiovascular diseases. 26 (60.47%) of 43 also received concomitant low dose aspirin. The median age of patients receiving PEG was 66 years (Range: 16 to 99 years) with 58% males. All patients underwent PEG tube placement by “pull technique”. Majority of the PEG tubes were placed for dysphagia related for stroke in 29 (67%) patients and for neurological-trauma in 13 patients (30%). In all 43 patients, both the clopidogrel and aspirin therapy was continued even on the day of procedure. The patients were followed for median time of 41 (Range: 1-973) days. None of the patients who received clopidogrel with or without aspirin had bleeding complications related to PEG tube placement. At 1 month, mortality occurred in 3 (7%) patients including 2 (12%) patients who received clopidogrel only and 1 (4%) who received concomitant aspirin (p=0.55). The mortality in all 3 patients was related to disease progression and was not related to PEG tube related complications. Conclusion: In our experience, uninterrupted clopidogrel therapy does not increase the rate of post PEG bleeding. In patients with strong indication to be on antiplatelet therapy, there is no need to hold these agents prior to PEG tube placement.