Does Aspirin Increase the Risk of Bleeding for Percutaneous Endoscopic Gastrostomy Procedure?

Abstract

Purpose: Bleeding is a potential complication of Percutaneous Endoscopic Gastrostomy (PEG). Aspirin is commonly used for associated co-morbid conditions in patients requiring PEG placement. Although aspirin is commonly withdrawn, the risk of bleeding while on aspirin has not been studied. The aim of the study is to determine the risk of bleeding for PEG tube placement in patients with aspirin. Methods: Records of 596 consecutive patients who had a PEG procedure as an inpatient were reviewed retrospectively. The incidence of bleeding was noted in patients who remained on aspirin or received aspirin within 5 days (Group A) and compared with patients who did not receive aspirin or in whom aspirin was stopped more than 7 days prior (Group B). The presence of coagulopathy, thrombocytopenia and other anti-platelet agents, including clopidogrel, was recorded. The primary outcome was overt bleeding within 48 hours, and secondary outcomes were drop of hemoglobin by 2 grams, any blood transfusion, or endoscopic intervention. Fisher's exact test was used to calculate the difference between the groups. Results: 42 patients were excluded due to discharge within 48 hours. Out of 554 patients, 190 (34.3%) patients were included in group A (Ages 27–98, median 79), and 364 (65.7%) were in group B (Ages 22–100, median 78). Bleeding was seen in 15 (2.7%) patients; 11(5.8%) in group A, and 4(0.01%) in Group B. This difference was statistically significant (p value = 0.004). Among bleeding patients, 3 patients in group A and 1 in group B were on Coumadin (INR 1.8–2.2) at the time of procedure. In addition, 3 patients in Group A and 1 patient in group B were on clopidogrel prior to the PEG placement. The risk of bleeding on aspirin remained statistically significant (p < 0.05) even after excluding patients with bleeding who had been on plavix or coumadin. Bleeding patients were managed by stopping the respective drug/s, transfusion (required in 2 patients, 1–3 units of pRBC), and 3 patients in group B required endoscopic therapy or gastric artery embolization. None of the patients in either group died from bleeding related complications. Conclusions: In this study, aspirin appears to increase the risk of bleeding in patients undergoing PEG procedure. However, the absolute risk of bleeding on aspirin following PEG placement was small and all were managed without endoscopic intervention. Concomitant use of Coumadin or other anti-platelet agents further increased the risk of bleeding.