Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Patients on Antiplatelet Agents

Abstract

Purpose: PEG tube placement is a common endoscopic procedure. A number of patients requiring PEG tubes are on antiplatelet agents. Little data exist that address the risk of post operative bleeding when PEG is performed with the patient still on antiplatelet agents. Aim: To determine the frequency of bleeding in patients taking Aspirin, Clopidogrel or both while having PEG tube placement and if this was affected by the number of days these agents were held prior to the procedure. Methods: We performed a retrospective review of 537 patients who had PEG tubes placed from1999–2007. Exclusion criteria included use of anticoagulants, an INR > 1.7, intubated patients, platelet count <50,000/μL, and incomplete documentation. Bleeding criteria was defined as hemoglobin drop >2 gm/dl, melena or hematochezia within 48 hrs of the procedure, the need for infusion of blood products or repeat endoscopy and readmission within one week of discharge for any GI bleeding. Patients divided in two groups. Group A (Aspirin, Clopidogrel or both within 5 days of the procedure): Group B (controls not on antiplatelet agents). History of PPI/H2 blocker, NSAIDS, SSRI's or Steroid use and previous ulcer disease were recorded. Results: 214 (64.8%) patients were included in Group A (Ages 27–98, median 79), and 116 (35.1%) were in Group B (Ages 22–100, median 78); 207 patients were excluded due to improper documentation. Bleeding was seen in 11 (5.1%) patients in Group A: 2 out of 85 patients on Aspirin alone and 2 out of 46 patients on Clopidogrel alone. (P= 0.215 and 0.140 respectively compared to controls); 7 out of 72 (10%) on Aspiring/Clopidogrel bled (P= 0.01 vs. controls). In Group B, 3 (2.6%) patients bled. Among bleeding patients, 2 were on Aspirin alone also on a NSAID and steroid; In the Clopidogrel alone group 2 patients were on NSAID and SSRI at the time of procedure. Bleeding patients were managed by stopping the respective drug/s, blood transfusion (required in 1 patient, 1 units of PRBC). No patient needed repeat endoscopy and there were no mortalities. Most patients in Group A stopped taking the antiplatelet agents 2–3 days prior to the procedure. All episodes of bleeding occurred if PEG placed between days 0–3 of stopping meds. No patients taking a PPI in this study bled. Conclusion: The combination of ASA and Clopidogrel increases the risk of post PEG bleeding especially when patients are on concomitant use of SSRI's, NSAIDS and steroids 2) Aspirin or Clopidogrel does not appear to significantly increase the risk of bleeding in patients undergoing PEG procedure. 3) Though bleeding appears to be minor, elective PEG should not be performed in patients on more than one antiplatelet agent.