Adverse Bleeding Events in Patients With Severe Thrombocytopenia Undergoing Endoscopy: A Systematic Review and Meta-Analysis

Introduction: Though gastrointestinal endoscopy is relatively safe, it may be complicated by post-procedure bleeding in the severely thrombocytopenic patient. International guidelines do not have a strong support for a specific platelet count necessary to safely perform gastrointestinal endoscopy, yet many institutions adhere to a pre-procedure goal of greater than 50,000/mL. Methods: A systematic review was performed by searching PubMed, Scopus, Google Scholar and Cochrane Libraries. Adult patients undergoing gastrointestinal endoscopy with a pre-procedure platelet count < 100,000/mL were included. Patients with cirrhosis were excluded. Meta-analysis of post-procedure bleed events based on Common Terminology Criteria for Adverse Events grading was performed. Results: Four studies were included from 449 unique citation results, providing data on 1,161 patients undergoing 1,557 procedures. Overall prevalence of all post-procedure bleeding was 83/1390 (6%) and 38/730 (5.2%) for post-biopsy bleeding. Grade 3 and 4 (< 50,000/mL) had higher odds of post-procedure bleeding compared to Grades 1 and 2 ( >50,000/mL) (OR 2.34, 1.35-4.05). There was no difference between Grade 3 (25-50,000/mL) and Grade 2 (50-75,000/mL) (OR 1.75, 0.93-3.29). There was also no difference among severity of thrombocytopenia and bleeding risk when post-biopsy data was isolated. Conclusion: Most low risk endoscopic procedures are likely safe in the severely thrombocytopenic patient, when considering bleed risk, and statistically significant bleeds only occur with counts less than 25,000/mL. Diagnostic endoscopy without intervention is likely safe at all platelet counts.