Antiplatelet Monotherapy Is Associated with an Increased Risk of Bleeding After Endoscopic Sphincterotomy

Background Clinical guidelines recommend continuing antiplatelet monotherapy with aspirin and, in certain situations, other antiplatelet agents in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. Aims Given the scant evidence supporting this recommendation, our primary objective was to determine if the risk of post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy. Methods We performed a systematic search of Cochrane Library, Ovid Embase, Ovid Medline, Pubmed, Scopus, and Web of Science Core Collection databases. Inclusion criteria were adult patients undergoing ERCP and sphincterotomy on antiplatelet monotherapy with the comparator of no antithrombotic therapy. Our primary outcome was post-sphincterotomy bleeding. Methodological quality was assessed with the ROBINS-I tool and the Newcastle-Ottawa Scale. Meta-analysis with random-effects model was performed. Results The search identified 4676 unique citations, with six cohort studies meeting our inclusion criteria. Post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy: OR = 1.53 (95% CI 1.03-2.28) without substantial heterogeneity (I-2 = 0%). The number needed to harm (the number of patients who would have to receive antiplatelet monotherapy for one additional patient to have a post-sphincterotomy bleeding episode) was 185(95% CI 80-2272). All included studies had methodological shortcomings. Conclusion Antiplatelet monotherapy was associated with a modestly increased risk of post-sphincterotomy bleeding in our systematic review and meta-analysis. More high-quality studies are needed to improve certainty regarding the estimated effect size. Registration PROSPERO CRD42020153019.

Automated summary

The use of antiplatelet monotherapy in patients undergoing sphincterotomy during ERCP is associated with an increased risk of post-procedure bleeding based on systematic review and meta-analysis. However, the quality of existing studies is limited and further high-quality research is required to confirm these findings.