1. Prof. 동석호
소화기내과 R2 윤수진

2. Introduction Clinically significant bleeding a/w EST and EPBD:
1%–5%, <1%
EST and EPBD in patients receiving antiplatelet agents and/or anticoagulants can increase the risk of severe bleeding during and after the procedure.
Several small retrospective studies have reported conflicting results on EST-related bleeding in patients receiving antiplatelet agents, and there are no available data on EST in patients receiving anticoagulants.

3. Patients and methods
Bile duct stones with or without biliary infection (ICD-10 code K80.3–80.5, 80.8) and were discharged between 2007 July 1 – 2012 March 31
Antiplatelet agents: aspirin, cilostazol, ticlopidine and clopidogrel, sarpogrelate, beraprost, icosapentate
Anticoagulants: warfarin, dabigatran

4. Results

6. Incidence of severe bleeding after EST and EPBD
Severe bleeding : 510 patients (0.8 %)
RBC transfusion, endoscopic hemostasis, transcatheter arterial embolization
RBC transfusion
the day of EST or EPBD(51); day 2(105); day 3(73); day 4(76)
Endoscopic hemostasis
the day of EST or EPBD(62); day 2(74); day 3(78); day 4(76)
Transcatheter arterial embolization
the day of EST or EPBD(5); day 2(7); day 3(2); day 4(4)
In-hospital mortality of any cause within 30 days occurred in 181 patients(0.3 %)

7. Incidence of severe bleeding in the EST and EPBD groups
The rate of severe procedure-related bleeding was the same
EST group(0.8% (n=456)) vs. EPBD group(0.8% (n=54) )
Warfarin
Fresh frozen plasma transfusion
EST(32 patients (0.6 %))and EPBD (5 patients (0.1 %))
Vit.K (iv)
EST(38 patients (0.7 %)) and EPBD(7 patients (0.1 %))

8. EPBD group was more likely to undergo the procedure with continuation of aspirin and tended to undergo the procedure with continuation of the remaining antiplatelet agents and anticoagulants too.

9. Impact of antiplatelet agents and anticoagulants on severe bleeding after EST
Antiplatetlet agent 를 중단유무는 severe bleeding risk에 영향이 없었습니다.
Anticoagulant의 경우는 중단할 경우 severe bleeding risk 가 증가하였으나 anticoagulant를 유지할 경우는 bleeding 과 상관이 없었습니다.
Anticoagulant를 non-users vs. users로 구분할 경우에도 429/52805(0.8%)와 27/1688(1.6%)로 users의 경우 bleeding risk가 증가합니다.

10. Impact of antiplatelet agents and anticoagulants on severe bleeding after EPBD
Antiplatetlet agent 를 중단유무는 severe bleeding risk에 영향이 없었습니다.
Anticoagulant의 경우는 중단/유지할 경우 severe bleeding risk가 증가하였습니다.
Anticoagulant를 non-users vs. users로 구분할 경우에도 8/263(3.0%)와 46/6246(0.7%)로 users의 경우 bleeding risk가 증가합니다.

11. Conclusions
EST and EPBD can be safely performed in patients receiving antiplatelet agents.
Users of anticoagulants are at high risk of bleeding, and the periprocedural management of these should be further investigated.

12. Thank you for listening