The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지

The Safety of Endoscopic Sphincterotomy in Patients Taking Aspirin

아스피린 복용 환자에서 내시경 유두 괄약근 절개술에 따른 출혈의 위험성

  • Hwang, Jong-Ho (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Kang, Dae-Hwan (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Kim, Hyung-Wook (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Choi, Choel-Woong (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Park, Soo-Bum (Department of Internal Medicine, Pusan National University School of Medicine)
  • 황종호 (부산대학교 의학전문대학원 내과학교실) ;
  • 강대환 (부산대학교 의학전문대학원 내과학교실) ;
  • 김형욱 (부산대학교 의학전문대학원 내과학교실) ;
  • 최철웅 (부산대학교 의학전문대학원 내과학교실) ;
  • 박수범 (부산대학교 의학전문대학원 내과학교실)
  • Published : 2011.08.01
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Abstract

Background/Aims: Endoscopic sphincterotomy (EST) is a common therapeutic technique for biliary and pancreatic disease, but it can cause several complications. Although the literature suggests that there is no need for patients to stop taking aspirin before undergoing EST, there are no definite guidelines on this in Korea. Consequently, we compared the frequency of bleeding and safety between aspirin users and nonusers undergoing EST. Methods: This retrospective study recruited 1003 patients who underwent EST at our hospital between 1 February 2005 and 30 September 2008. Thirteen patients continued to take aspirin until the day of the sphincterotomy (group 1), and 990 patients had not taken aspirin before the sphincterotomy (group 2). The incidence of post-sphincterotomy bleeding was compared between the two groups retrospectively. Results: There was no significant difference in age or gender between the two groups. The indications for EST included common bile duct stones in 12 patients (92.3%, 12/13) in group 1 and 706 patients (71.3%, 706/990) in group 2 (p = 0.124). Regarding combined disease, cholangitis was observed in 11 patients (84.6%, 11/13) in group 1 and 815 patients (82.3%, 815/990) in group 2 (p = 0.974). Clinically significant post-sphincterotomy bleeding was observed in three patients in group 2 (0.3%, 3/990) versus none in group 1. Conclusions: Taking aspirin does not appear to clinically increase bleeding after EST. Therefore, there is no definite need to stop aspirin before undergoing EST.

목적: 내시경 유두 괄약근절개술(endoscopic sphicterotomy, EST)은 현재 췌장과 담도 질환에서 널리 사용되는 내시경적 치료방법이나 출혈, 천공, 췌장염의 합병증이 동반될 수 있다. 외국 문헌에 따르면 EST 시행 전 아스피린(aspirin)을 중단할 필요가 없다고 제시하고 있다. 최근 국내에서도 아스피린의 복용자가 늘어나고 있음에도 불구하고 현재 이에 대한 적절한 지침이 없는 실정이다. 따라서 EST를 시행한 환자들에서 아스피린 복용 군과 비 복용 군의 출혈에 대한 빈도와 안전성에 대해 비교 평가하고자 하였다. 방법: 2005년 2월부터 2008년 9월까지 본원에서 EST를 시행한 1,003명을 대상으로 하였고, 13명이 시술 전 지속적으로 아스피린을 복용한 군이었으며 나머지 990명이 아스피린을 복용하지 않은 군이었다. 각 그룹 간에 EST 시행 후 출혈 빈도를 후향적으로 비교 분석하였다. 결과: 아스피린 복용 군과 비복용 군 간에 연령, 성별에서는 통계학적 차이를 보이지 않았다. EST 적응증으로 담관담석이 아스피린 복용 군에서 12예(92.3%, 12/13예), 비 복용군에서 706예(71.3%, 706/990예)였으며(p = 0.124) 동반된 질환으로 담도염이 아스피린 복용 군에서 11예(84.6%, 11/13 예), 비 복용 군에서 815예(82.3%, 815/990 예)로 (p = 0.974) 두 군 간에 별다른 차이를 보이지 않았다. 임상적으로 의미있는 출혈은 아스피린 복용 군에서는 발견되지 않았으며 아스피린 비 복용 군에서 3예(0.3%, 3/990예)가 관찰되었다. 결론: 본 연구에서는 아스피린을 복용하는 것이 EST 후 임상적으로 의미 있는 출혈을 증가시키지는 않았다. 따라서 EST를 시행하기 전에 아스피린의 복용을 반드시 중단할 필요는 없을 것으로 생각한다.

Keywords

References

  1. Classen M, Demling L. Endoscopic sphincterotomy of the papilla of vater and extraction of stones from the choledochal duct (author's transl). Dtsch Med Wochenschr 1974;99:496-497. https://doi.org/10.1055/s-0028-1107790
  2. Kawai K, Akasaka Y, Murakami K, Tada M, Koli Y. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20:148-151. https://doi.org/10.1016/S0016-5107(74)73914-1
  3. Leese T, Neoptolemos JP, Carr-Locke DL. Successes, failures, early complications and their management following endoscopic sphincterotomy: results in 394 consecutive patients from a single center. Br J Surg 1985;72:215-219. https://doi.org/10.1002/bjs.1800720325
  4. Classen M, Born P. Endoscopic papillotomy, syn. sphincterotomy: results from the past two years. Curr Gastroenterol Rep 2004;6:169-175. https://doi.org/10.1007/s11894-004-0045-y
  5. Kwon OY, Seo JD, Kim KI, et al. A clinical study on 586 cases of ERCPO. Korean J Med 1985;28:453-459.
  6. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-918. https://doi.org/10.1056/NEJM199609263351301
  7. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-393. https://doi.org/10.1016/S0016-5107(91)70740-2
  8. Laine L. Approaches to nonsteroidal anti-inflammatory drug use in the high-risk patient. Gastroenterology 2001;120:594-606. https://doi.org/10.1053/gast.2001.21907
  9. Grauamlich JF. Preventing gastrointestinal complications of NSAIDs: risk factors, recent advances, and latest strategies. Postgrad Med 2001;109:117-120, 123-128.
  10. Hill JO, Maxwell AJ, Tweedle DEF, et al. Do measured parameters of blood clotting help predict haemorrhage after endoscopic sphincterotomy? Gut 1990;31:A608 (Abstract).
  11. Sherman S. Outpatient therapeutic ERCP. has the time come? Gastrointest Endosc 1997;45:326-328. https://doi.org/10.1016/S0016-5107(97)70285-2
  12. Ryan ME. Avoidance of aspirin and nonsteroidal anti-inflammatory drugs prior to endoscopic sphincterotomy. Gastrointest Endosc 1990;36:199 (Abstract).
  13. 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. https://doi.org/10.1016/S0016-5107(02)70402-1
  14. Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005;61:189-194. https://doi.org/10.1016/S0016-5107(04)02392-2
  15. Anderson MA, Ben-Menachem T, Gan SI, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009;70:1060-1070. https://doi.org/10.1016/j.gie.2009.09.040
  16. Freeman ML. Complications of endoscopic biliary sphincterotomy: a review. Endoscopy 1997;29:288-297. https://doi.org/10.1055/s-2007-1004193
  17. Safrany L. Endoscopic treatment of biliary tract diseases: an international study. Lancet 1978;2:983-985.
  18. Cotton PB. Endoscopic management of bile duct stones: (apples and oranges). Gut 1984;25:587-597. https://doi.org/10.1136/gut.25.6.587
  19. Kim MH. Bleeding after EST. Korean J Gastrointest Endosc 2003;27:319-320.
  20. Kadakia SC, Angueira CE, Ward JA, Moore M. Gastrointestinal endoscopy in patients taking antiplatelet agents and anticoagulants: survey of ASGE members: American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1996;44:309-316. https://doi.org/10.1016/S0016-5107(96)70170-0
  21. Hussain N, Alsulaiman R, Burtin P, et al. The safety of endoscopic sphincterotomy in patients receiving antiplatelet agents: a case-control study. Aliment Pharmacol Ther 2007;25:579-584.
  22. Hui CK, Lai KC, Yuen MF, Wong WM, Lam SK, Lai CL. Does withholding aspirin for one week reduce the risk of postsphincterotomy bleeding? Aliment Pharmacol Ther 2002;16:929-936. https://doi.org/10.1046/j.1365-2036.2002.01251.x
  23. Szczeklik A, Krzanowski M, Gora P, Radwan J. Antiplatelet drugs and generation of thrombin in clotting blood. Blood 1992;80:2006-2011.
  24. Patrono C. Aspirin as an antiplatelet drug. N Engl J Med 1994;330:1287-1294. https://doi.org/10.1056/NEJM199405053301808
  25. Patrono C. Aspirin: new cardiovascular uses for an old drug. Am J Med 2001;110:S62-S65. https://doi.org/10.1016/S0002-9343(00)00645-8