[Anticoagulation and antiplatelet therapy, and gastrointestinal endoscopy]

Serotonin reuptake inhibitors and post-gastrostomy bleeding: reevaluating the link

Introduction

Serotonin reuptake inhibitors (SRIs) are one of the most commonly prescribed classes of medications with a relatively safe side-effect profile. However, SRIs are being increasingly reported to be associated with bleeding complications in patients undergoing invasive procedures resulting from inhibition of serotonin reuptake by platelets and impaired platelet aggregation. The aim of our study was to determine whether there is an increased risk of post-percutaneous endoscopic gastrostomy (PEG) bleeding in patients exposed to SRIs after controlling for other mediations known to increase the risk of bleeding and major comorbidities.

Methods

This was a single-center cohort study that included who underwent PEG tube placement by standard pull-guidewire technique from July 2006 to June 2014. Patients were categorized into groups based on the medications (SRIs, aspirin, non-steroidal anti-inflammatory drugs, and anticoagulants) administered during the index hospitalization. The incidence of post-PEG bleeding was noted in two distinct post-procedure periods: within 48 hours, and between 48 hours and 14 days.

Results

A total of 637 PEG tube placements were done on 570 patients during the study period. There were 107 patients (18.8%) with major bleeding within 48 hours of PEG and 79 patients (13.9%) with major bleeding between 48 hours and 14 days. There was no significant increase in the post-PEG bleeding in patients taking a combination of an SRI along with aspirin or non-steroidal anti-inflammatory drugs. Patients on subcutaneous heparin for prophylaxis against thromboembolic events were more likely to have oozing at the PEG site requiring blood transfusion.

Conclusion

We did not notice an increase in post-PEG bleeding in patients on SRIs. However, in view of the limitation that our study is retrospective and that there are no known significant side effects of withdrawal of SRIs for a short duration, withholding SRIs could be a safe clinical option in patients undergoing PEG tube placement.

[Digestive system endoscopy in the elderly and in patients with severe comorbidities]

Besides the technical equipment, the endoscopic team's theoretical and practical skills, the success of endoscopic intervention is influenced by the patient's general condition. Advanced age, severe co-morbidities may increase the risk, especially in case of operative endoscopy. The decision is more complicated when alarm symptoms urge the examination. The endoscopic examination of digestive system, biliary track and pancreas in advanced age can safely be performed as alternatives of surgical intervention. It is important to know the exact stage of cardiovascular and pulmonary diseases, besides, in case of stroke the patient's cooperation is very important. In everyday practice the most common problems are the endoscopic examination of the patient in oral anticoagulant and/or thrombocyte aggregation inhibition therapy and the question of suspending, modifying or restarting the therapy. Examining the patients with implanted electronic device as well as antibiotic prophylaxis in expanding range of indications are special issues. The gastroenterologist makes the decision based on the knowledge of the endoscopic intervention, the patient's risk classification, the indications, the contradictions and the alternative diagnostic possibilities. This review attempts to give an overview with some practical aspects.