Skip to main content
SpringerLink
Log in

Risk of Bleeding After Percutaneous Endoscopic Gastrostomy (PEG)

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited.

Aims

To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG.

Methods

A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011.

Results

A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively.

Conclusion

Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ASGE:

American Society for Gastrointestinal Endoscopy

APTT:

Activated partial thromboplastin time

GI:

Gastrointestinal

LMWH:

Low-molecular-weight heparin

PEG:

Percutaneous endoscopic gastrostomy

References

  1. Eisen GM, Baron TH, Dominitz JA, et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002;55:775–779.

    Article  PubMed  Google Scholar 

  2. Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johnston TK. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc. 2002;55:307–314.

    Article  PubMed  Google Scholar 

  3. Hui AJ, Wong RM, Ching JY, Hung LC, Chung SC, Sung JJ. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc. 2004;59:44–48.

    Article  PubMed  Google Scholar 

  4. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–918.

    Article  PubMed  CAS  Google Scholar 

  5. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc. 2004;60:721–731.

    Article  PubMed  Google Scholar 

  6. Schapiro GD, Edmundowicz SA. Complications of percutaneous endoscopic gastrostomy. Gastrointest Endosc Clin North Am. 1996;6:409–422.

    CAS  Google Scholar 

  7. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy indications, success, complications and mortality in 314 consecutive patients. Gastroenterology. 1987;93:48–52.

    PubMed  CAS  Google Scholar 

  8. Sarin SK, Lamba GS, Kumar M, Misra A, Murthy NS. Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding. N Engl J Med. 1999;340:988–993.

    Article  PubMed  CAS  Google Scholar 

  9. Lo GH, Lai KH, Cheng JS, Lin CK, Hsu PI, Chiang HT. Prophylactic banding ligation of high-risk esophageal varices in patients with cirrhosis: a prospective, randomized trial. J Hepatol. 1999;31:451–456.

    Article  PubMed  CAS  Google Scholar 

  10. Gauderer MW. Twenty years of percutaneous endoscopic gastrostomy: origin and evolution of a concept and its expanded applications. Gastrointest Endosc. 1999;50:879–883.

    Article  PubMed  CAS  Google Scholar 

  11. Makar GA, Ginsberg GG. Therapy insight: approaching endoscopy in anticoagulated patients. Nat Clin Pract Gastroenterol Hepatol. 2006;3:43–52 (Review).

    Google Scholar 

  12. Juul-Moller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R. Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet. 1992;340:1421–1425.

    Article  PubMed  CAS  Google Scholar 

  13. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Google Scholar 

  14. Bhatt DL, Fox KA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354:1706–1717.

    Article  PubMed  CAS  Google Scholar 

  15. The SALT Collaborative Group. Swedish Aspirin Low-Dose Trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. Lancet. 1991;338:1345–1349.

    Google Scholar 

  16. Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med. 1989;321:129–135.

    Google Scholar 

  17. Luman W, Kwek KR, Loi K, Chiam MA, Cheung WK, Ng HS. Percutaneous endoscopic gastrostomy-indications and outcome of our experience at the Singapore General Hospital. Singapore Med J. 2001;42:460–465.

    PubMed  CAS  Google Scholar 

  18. Richter JA, Patrie JT, Richter RP, et al. Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel. Gastrointest Endosc. 2011;74:22–34.

    Article  PubMed  Google Scholar 

  19. NapolÈon B, Boneu B, Maillard L, et al. Board of the French Society for Digestive Endoscopy (SFED). Guidelines of the French Society for Digestive Endoscopy (SFED). Endoscopy. 2006;38:632–638.

    Article  PubMed  Google Scholar 

  20. ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70:1061–1070.

    Article  Google Scholar 

  21. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2008;52:1502–1517.

    Article  PubMed  Google Scholar 

  22. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: Results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–2870.

    Article  PubMed  CAS  Google Scholar 

  23. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994;154:1449–57. (Erratum in 1994;154:2254).

    Google Scholar 

  24. Research Committee of the British Thoracic Society. Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Lancet 1992;340:873–876.

    Google Scholar 

  25. European Heart Rhythm Association, Heart Rhythm Society, Fuster V, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006;48:854–906.

    Google Scholar 

  26. Lee SY, Tang SJ, Rockey DC, et al. Korean Association for the study of intestinal disease. Managing anticoagulation and antiplatelet medications in GI endoscopy: a survey comparing the East and the West. Gastrointest Endosc. 2008;67:1076–1081.

    Google Scholar 

  27. Fujishiro M, Oda I, Yamamoto Y, et al. Multi-center survey regarding the management of anticoagulation and antiplatelet therapy for endoscopic procedures in Japan. J Gastroenterol Hepatol. 2009;24:214–218. Epub. 09/24/2008.

    Google Scholar 

  28. Goel A, Barnes CJ, Osman H, Verma A. National survey of anticoagulation policy in endoscopy. Eur J Gastroenterol Hepatol. 2007;19:51–56.

    Article  PubMed  Google Scholar 

  29. Mosler P, Mergener K, Denzer U, Kiesslich R, Galle PR, Kanzler S. Current practice in managing patients on anticoagulants and/or antiplatelet agents around the time of gastrointestinal endoscopy—a nation-wide survey in Germany. Z Gastroenterol. 2004;42:1289–1293.

    Article  PubMed  CAS  Google Scholar 

  30. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc. 1981;27:9–11.

    Article  PubMed  CAS  Google Scholar 

  31. Cotton P, Williams C. Practical Gastrointestinal Endoscopy. 4th ed. Oxford: Alden Press; 1996:168.

  32. Pender SM, Courtney MG, Rajan E, McAdam B, Fielding JF. Percutaneous endoscopic gastrostomy; results of an Irish single unit series. Ir J Med Sci. 1993;162:452–455.

    Article  PubMed  CAS  Google Scholar 

  33. Gibson SE, Wenig BL, Watkins JL. Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Otol Rhinol Laryngol. 1992;101:46–50.

    PubMed  CAS  Google Scholar 

  34. Disario J. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20:605–630.

    Article  PubMed  Google Scholar 

  35. Lin HS, Ibrahim HZ, Kheng JW, Fee WE, Terris DJ. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications. Laryngoscope. 2001;111:1847–1852.

    Article  PubMed  CAS  Google Scholar 

  36. Cappell MS, Abdullah M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol Clin North Am. 2000;29:125–167.

    Article  PubMed  CAS  Google Scholar 

  37. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005;293:2126–2130.

    Article  PubMed  CAS  Google Scholar 

  38. Kim HS, Kim TI, Kim WH, et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol. 2006;101:1333–1341.

    Article  PubMed  Google Scholar 

  39. Sawhney MS, Salfiti N, Nelson DB, Lederle FA, Bond JH. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy. 2008;40:115–119.

    Article  PubMed  CAS  Google Scholar 

  40. Singh M, Mehta N, Murthy UK, Kaul V, Arif A, Newman N. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc. 2010;71:998–1005.

    Article  PubMed  Google Scholar 

  41. Ruthmann O, Seitz A, Richter S, et al. Percutaneous endoscopic gastrostomy. Complications with and without anticoagulation. Chirurg. 2010;81:247–254.

    Article  PubMed  CAS  Google Scholar 

  42. Witt DM, Delate T, McCool KH, et al. WARPED Consortium. Incidence and predictors of bleeding or thrombosis after polypectomy in patients receiving and not receiving anticoagulation therapy. J Thromb Haemost. 2009;7:1982–1989. Epub. 08/28/2009.

    Google Scholar 

  43. Baglin TP, Keeling DM, Watson HG. Guidelines on oral anticoagulation (warfarin): third edition—2005 update. Br J Haematol 2006;1:277–285. Gut. 2008;57:1322-1329. Epub. 05/9/2008.

    Google Scholar 

  44. Veitch AM, Baglin TP, Gershlick AH, et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut. 2008;57:1322–1329. Epub. 05/9/2008.

    Google Scholar 

  45. Ansell JE. The perioperative management of warfarin therapy. Arch Intern Med. 2003;163:881–883.

    Article  PubMed  Google Scholar 

  46. Turpie AG, Antman EM. Low-molecular-weight heparins in the treatment of acute coronary syndromes. Arch Intern Med. 2001;161:1484–1490.

    Article  PubMed  CAS  Google Scholar 

  47. Kadayifci A, Haznedaroglu I, Savas M. Risk of withdrawing chronic anticoagulation without antithrombotic prophylaxis. Am J Gastroenterol. 1997;92:361–362.

    PubMed  CAS  Google Scholar 

  48. Spyropoulos AC, Turpie A. Perioperative bridging interruption with heparin for the patient receiving long-term anticoagulation. Curr Opin Pulm Med. 2005;11:373–379.

    PubMed  CAS  Google Scholar 

  49. Constans M, Santamaria A, Mateo J, Pujol N, Souto JC, Fontcuberta J. Low-molecular-weight heparin as bridging therapy during interruption of oral anticoagulation in patients undergoing colonoscopy or gastroscopy. Int J ClinPract. 2007;61:212–217.

    Google Scholar 

  50. Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol. 2009;104:3085–3097; quiz 3098. Epub. 08/11/2009. Review.

    Google Scholar 

Download references

Conflict of interest

Authors do not have any conflicts (financial, professional, or personal) relevant to the manuscript.

Author information

Authors and Affiliations

  1. Section of Gastroenterology, University of Missouri Kansas City, Kansas City, MO, USA

    Dushyant Singh, Alexandra S. Laya & Wendell K. Clarkston

  2. Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA

    Omkar U. Vaidya & Syed A. Ahmed

  3. Department of Biomedical and Health Informatics, University of Missouri Kansas City, Kansas City, MO, USA

    Aaron J. Bonham

  4. Section of Gastroenterology, Saint Luke’s Hospital, Kansas City, MO, USA

    Wendell K. Clarkston

  5. Graduate Medical Education (3rd Floor), Saint Luke’s Hospital, 4401 Holmes St, Kansas City, MO, 64111, USA

    Dushyant Singh

Authors
  1. Dushyant Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexandra S. Laya
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Omkar U. Vaidya
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Syed A. Ahmed
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Aaron J. Bonham
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Wendell K. Clarkston
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dushyant Singh.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Singh, D., Laya, A.S., Vaidya, O.U. et al. Risk of Bleeding After Percutaneous Endoscopic Gastrostomy (PEG). Dig Dis Sci 57, 973–980 (2012). https://doi.org/10.1007/s10620-011-1965-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-011-1965-7

Keywords

Search

Navigation