Does anticoagulation (blood thinner) therapy need to be held for Percutaneous Endoscopic Gastrostomy (PEG) placement?

From the Guidelines

Anticoagulation therapy does not always need to be held for Percutaneous Endoscopic Gastrostomy (PEG) placement, but it depends on the type of anticoagulant and the patient's individual risk factors, as outlined in the guidelines from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute 1.

Key Considerations

• For warfarin, the INR should be less than 1.5 before the procedure, and if it's greater than 1.5, it should be corrected before proceeding 1.
• Clopidogrel should be withheld for 5 days before the procedure, while aspirin can be continued without interruption 1.
• Low molecular weight heparin (therapeutic dose) should be withheld one dose before the procedure 1.
• The decision to hold anticoagulation therapy should be based on the individual patient's risk of bleeding and thromboembolic complications, as well as the specific procedure being performed.

Procedure-Specific Risks

• PEG placement is considered a high-risk procedure for bleeding, involving puncture through the abdominal wall and stomach with potential for bleeding from gastric vessels or the insertion site 1.
• The risk of bleeding and thromboembolic complications should be carefully weighed against the benefits of continuing anticoagulation therapy during the perioperative period.

Patient-Specific Factors

• Patients with high thrombotic risk may require bridging therapy with heparin during the perioperative period, which should be determined through consultation between gastroenterology and the service managing the patient's anticoagulation 1.
• The patient's individual risk factors, such as renal impairment or history of bleeding complications, should be taken into account when making decisions about anticoagulation therapy during PEG placement.

From the Research

Anticoagulation and PEG Placement

• The need to hold anticoagulation therapy for Percutaneous Endoscopic Gastrostomy (PEG) placement is a topic of discussion among medical professionals.
• Studies have shown that the risk of bleeding associated with PEG placement is minimal in patients on uninterrupted periprocedural antithrombotic therapy 2.
• A study published in 2010 found that complications of PEG placement, including bleeding, are rare, and an increased risk of bleeding during therapeutic anticoagulation was not observed 3.
• Another study published in 2015 found that maintaining aspirin and/or clopidogrel treatment does not increase the risk of bleeding following PEG placement 4.
• A retrospective study published in 2012 found that prophylactic anticoagulation use did not affect bleed risk with PEG, and platelet count was significantly lower in patients with a bleeding event 5.
• A chart audit published in 2012 found that bleeding after PEG placement was rare, even with the use of anticoagulation and antiplatelet medications, and heparin infusion was a statistically significant predictor of bleeding 6.

Key Findings

• The risk of significant bleeding associated with PEG placement is minimal in patients on uninterrupted periprocedural antithrombotic therapy 2.
• Anticoagulation therapy can be continued in selected patients undergoing PEG placement without an increased risk of bleeding 3, 4.
• The use of antiplatelet therapy, such as aspirin and clopidogrel, does not increase the risk of bleeding after PEG placement 4, 6.
• Heparin infusion is a predictor of bleeding after PEG placement, and close monitoring and frequent assessments should be considered in patients on heparin infusion undergoing PEG 6.