PTU-116 Delayed post sphincterotomy bleeding and management – 4 year single centre experience

Introduction Bleeding from endoscopic sphincterotomy (ES) is an important complication of therapeutic ERCP. The frequency of post sphincterotomy bleeding is estimated at 0.3% to 2%. Delayed bleeding can occur anytime from hours up to two weeks after ES. Although several studies have addressed the risk factors for bleeding after ES, there is less information specifically on delayed bleeding. Aims This study examines factors that influence delayed post ES related bleeding, and reviews its management and outcomes. Methods We reviewed the records of patients who underwent an OGD within 4 weeks of having an ERCP procedure performed by a gastroenterologist between 2015 to 2018 at the Royal Gwent and Nevill Hall hospitals. Results Over a 4 year period, 39 patients had an OGD within 4 weeks after an ERCP procedure. Of these, 17 had experienced delayed post ES bleeding at a median of 6 days (range1–10). The frequency of delayed post ES bleeding in our centre was 1.8%. Most were male 12/17(70%) and the mean age was 74 years (range 45–97). Patients presented with melaena (41%), hematemesis (24%), haematochezia(6%) or melaena with hematemesis(30%). Out of the 17 patients, three were on aspirin, two were on clopidogrel and three were on warfarin. One had thrombocytopenia and three had a prothrombin time more than 13 seconds. Two had chronic kidney disease and ischaemic heart disease of which one patient was on regular dialysis. Indications for ES were choledocholithiasis (76%), cholangitis (12%) and malignancy (12%). Endotherapy was applied with the following modalities, singly or in combination: adrenaline injection(2 patients), adrenaline injection and heater probe(1 patient), adrenaline injection and hemospray(4 patients), endoscopic clips(1 patient), adrenaline injection and clips(2 patients) and hemospray alone (1 patient). No endotherapy was offered in 6 patients and were managed conservatively. One re-bled in 24 hours and responded to repeat endotherapy with adrenaline injection and hemospray. Four failed endotherapy and needed angiographic embolization. There were no deaths. Conclusion This study emphasizes that factors such as thrombocytopenia, antiplatelet drugs, anticoagulants and cholangitis confer an increased risk of delayed post sphincterotomy bleeding. Patients who undergo ERCP with sphincterotomy should be warned about the 1.8% risk of delayed bleeding. Current guidelines suggest that ES can be done safely in patients on Aspirin. We recommend larger studies to interrogate the safety of continuing Aspirin in such patients.