INTRODUCTION: Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients. METHODS: A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality. RESULTS: A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics. DISCUSSION: In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

Background and Hypothesis: Diabetic retinopathy (DR), the leading microvasculature and blindness-causing complication of diabetes mellitus, can be diagnosed and monitored using optical coherence tomography angiography (OCT-A) to visualize all retinal vasculature layers with greater resolution and limited invasiveness compared to the established technique of fluorescein angiography. We hypothesize that OCT-A can be used as a biomarker to correlate retinal vessel density (VD) from OCT-A with clinical severity of DR, visual acuity, and patient demographics as well as track anti-vascular endothelial growth factor (VEGF) treatment efficacy.  Methods: This retrospective cohort study analyzed the automatically quantified VDs of the superficial vascular complex (SVC) and deep vascular complex (DVC), including the whole, foveal, and parafoveal VDs, on quality OCT-A scans in patients with diagnosed DR. A multivariate linear regression and ANOVA analysis was completed to compare VDs to DR severity, visual acuity, and demographic factors in patients with at least one quality OCT-A scan. A linear mixed analysis was performed to determine how VD was affected by whether anti-VEGF therapy was given to patients with OCT-A scans at two or more different timepoints.   Results: There was found to be a positive correlation of the VDs in both the SVC whole and parafoveal VD and DVC parafoveal VD with decreased DR severity and increased visual acuity in the cross-sectional analysis (p ≤0.001). The DVC whole VD was also positively correlated with increased visual acuity (p<0.001). There was no difference in the VDs associated with anti-VEGF treatment over time.  Conclusions and Potential Impact: OCT-A shows promise for the diagnosis and monitoring of DR as a biomarker for disease severity which correlates with visual acuity. Anti-VEGF did not show significant change in VD in DR patients. Longer follow-up periods may be needed to elaborate on the long-term effects of anti-VEGF.

Background: Patients with cirrhosis may be at increased risk of bleeding after invasive procedures due to defects in coagulation; however the bleeding risk following therapeutic endoscopy remains poorly understood. We aimed to determine the incidence and risk factors for post-procedural bleeding for patients with cirrhosis undergoing therapeutic endoscopy. Methods: We performed a retrospective cohort study of patients undergoing three common endoscopic procedures (colonoscopic polypectomy, endoscopic variceal ligation, and biliary sphincterotomy) at Indiana University Hospital between 2007 and 2014. Clinical and procedural data were collected, including complications in the 30 days following the proceduress.  Results: We identified 447 procedures: 128 polypectomies, 63 sphincterotomies, and 256 variceal ligations. The incidence of bleeding was 2% (4 polypectomies, 1 sphincterotomy, and 4 variceal ligations) after a median of 4.5 days. . Prophlactic platelet transfusions were provided to 11 patients and plasma was transfused in 17 patients. Of those who received prophylactic transfusions, only one bled (post-polypectomy despite prophylactic hemoclip placement). The patients that bled had a median INR of 1.48 which was slightly elevated compared to the overall median INR 1.26. Post-polypectomy bleeding occurred following removal of fairly large polyps (8, 9, 10, 25 mm) compared to the median overall polyp size of 5 mm.   Conclusion: The incidence of bleeding for patients with cirrhosis undergoing therapeutic endoscopy is low. More data on post-procedural bleeding are needed to determine risk factors and to inform appropriate prophylactic measures. These data may be used to guide clinicians in counseling patients prior to these procedures.