Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy

Delphi consensus statement for the management of delayed post-polypectomy bleeding

Background

Delayed post-polypectomy bleeding (DPPB) is the most common adverse event following colonic polypectomy, yet its management remains highly heterogeneous and lacks standardization. A considerable number of colonoscopies performed for DPPB may be unnecessary and do not result in hemostatic intervention.

Objectives

To develop evidence-based statements to guide clinical decision-making in DPPB.

Design

Multidisciplinary Delphi consensus statement.

Methods

A panel of 29 experts in gastroenterology, hematology, radiology, and surgery was assembled. Through a systematic review of the literature and a modified Delphi process, consensus statements were developed through iterative rounds of anonymous voting. Statements were revised following anonymous voting and feedback at each round. Those achieving 80% agreement were accepted.

Results

The expert panel reached a consensus on 36 statements, covering areas such as antithrombotic management, bowel preparation, colonoscopy indications, and therapeutic hemostatic modalities. Key recommendations include guidance for managing self-limited bleeding and risk stratification to reduce the rate of unnecessary colonoscopies, as well as recommendations for hemodynamically unstable patients who may require primary angioembolization. A practical clinical algorithm is proposed.

Conclusion

This document provides a consensus-based framework for managing DPPB. These recommendations aim to improve patient outcomes and optimize healthcare resources while fostering a standardized approach to this common adverse event.

Daily Antiplatelets Other Than Aspirin Reduce Liver Cancer Risk but Increase Intracranial Hemorrhage Risk in Cirrhotic Patients

Purpose

Aspirin, known to reduce the risk of liver cancer, has been proposed as a preventive measure for patients with chronic hepatitis and cirrhosis. However, concerns regarding aspirin's potential to cause gastrointestinal (GI) mucosal injury and bleeding have emerged. Several antiplatelets other than aspirin (APOA) that pose a smaller risk of GI bleeding than aspirin have been proposed as potential aspirin substitutes. This study investigated whether APOAs were effective at reducing the risk of hepatocellular carcinoma (HCC). Additionally, we evaluated the safety of APOAs, specifically regarding their potential to increase the risk of GI bleeding, in a nationwide cirrhosis cohort.

Patients and Methods

For the period January 1, 2000, to December 31, 2017, we identified 686 993 patients with cirrhosis from a national database. A control group was established using 1:2 propensity score matching on the basis of sex, age, comorbidities, and medication use.

Results

Daily use of APOAs was significantly associated with lower incidences of HCC (aHR 0.67; 95% CI, 0.60-0.73; P < 0.001) and showed no significant increase in GI bleeding risk (aHR 1.04; 95% CI, 0.93-1.15; P = 0.533) compared to nonuse of APOAs. However, the risks of intracranial hemorrhage (aHR, 1.41; 95% CI, 1.18 to 1.69; P < 0.001) and overall mortality (aHR, 2.03; 95% CI, 1.95 to 2.10; P < 0.001) were higher in the APOA user group.

Conclusion

Our results suggest that although daily use of APOAs other than aspirin may decrease the HCC risk of patients with cirrhosis, it may also increase their risks of intracranial hemorrhage and overall mortality. Therefore, the use of APOAs as an alternative to aspirin for HCC prevention in patients with cirrhosis requires careful consideration.

International Digestive Endoscopy Network Consensus on the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy

Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

[IDEN Consensus on Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]

Antithrombotic agents, including antiplatelet agent and anticoagulants are widely used in Korea due to increasing incidence of cardio-cerebrovascular disease and aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. Clinical practice guideline regarding this issue which was developed by the Korean Society of Gastrointestinal Endoscopy was published in 2020. However, since then, new evidence has emerged for the use of dual antiplatelet therapy and direct anticoagulant management, and revised guidelines were issued in the US and Europe. Accordingly, the previous guidelines were revised, cardiologists also participated in the development group, and the recommendations went through a consensus process among international experts. This guideline presents 14 recommendations made according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and was reviewed by multidisciplinary experts. This guideline provides useful information that can assist endoscopists in the management of patients on antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy

Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.