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Valenti MR, Cavallaro A, Di Vita M, Zanghi A, Longo Trischitta G, Cappellani A. Gallbladder hemorrhage-An uncommon surgical emergency: A case report. World J Clin Cases 2022; 10:9734-9742. [PMID: 36186197 PMCID: PMC9516921 DOI: 10.12998/wjcc.v10.i27.9734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/14/2021] [Accepted: 06/30/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gallbladder hemorrhage is a life-threatening disorder. Trauma (accidental or iatrogenic such as a percutaneous biopsy or cholecystectomy surgery), cholelithiasis, biliary tract parasitosis, vasculitis, vascular malformations, autoimmune and neoplastic diseases and coagulopathies have been described as causes of hemorrhage within the lumen of the gallbladder. The use of non-steroidal anti-inflammatory drugs and anticoagulants may represent a risk factor. CASE SUMMARY We report the case of a 76-year-old male patient. An urgent contrast computed tomography scan demonstrated relevant distension of the gallbladder filled with hyperdense non-homogeneous content. The gallbladder walls were of regular thickness. Near the anterior wall a focus of suspected active bleeding was observed. Due to the progressive decrease in hemoglobin despite three blood transfusions, this was an indication for urgent surgery. CONCLUSION Early diagnosis of this potentially fatal pathology is essential in order to plan a strategy and eventually proceed with urgent surgical treatment.
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Affiliation(s)
- Maria Rosaria Valenti
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
| | - Andrea Cavallaro
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
| | - Maria Di Vita
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
| | - Antonio Zanghi
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
| | - Giovanni Longo Trischitta
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
| | - Alessandro Cappellani
- Department of Surgery, University of Catania Medical School, University of Catania, Catania 95123, Italy
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Emergency Department Diagnosis of Postprocedural Hemorrhagic Cholecystitis Utilizing Point-of-Care Ultrasoun. J Emerg Med 2022; 62:e69-e77. [PMID: 35031169 DOI: 10.1016/j.jemermed.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/09/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hemorrhagic cholecystitis is a rare cause of abdominal pain. Most often described in the setting of blunt abdominal trauma, anticoagulation use, coagulopathy (such as cirrhosis or renal failure), and malignancy (biliary angiosarcoma), this rare condition can be difficult to identify unless high on the differential. With point-of-care ultrasound becoming more commonplace in the emergency department (ED), this tool can be successfully used to make a timely diagnosis in the correct clinical context. CASE REPORT A 64-year-old man with a past medical history of paroxysmal atrial fibrillation status post ablation on rivaroxaban, myelodysplastic syndrome, nonalcoholic steatohepatitis, gastroesophageal reflux disease, clonal cytopenias of undetermined significance, hypertension, and chronic pain presented to the ED with complaints of right upper quadrant pain in the setting of a recent transjugular liver biopsy. Using point-of-care ultrasound, the patient was diagnosed with hemorrhagic cholecystitis. This is an incredibly rare entity, with 87 documented cases in the literature, only two of which are in the setting of transjugular liver biopsy. The patient was ultimately managed conservatively until he had worsening symptoms, and a laparoscopic cholecystectomy was performed. The patient tolerated the procedure well and recovered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hemorrhagic cholecystitis is a rare pathology that can be easily recognized during point-of-care ultrasound examination. This allows for rapid diagnosis and surgical consultation to provide the patient with timely definitive management.
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Jang H, Park CH, Park Y, Jeong E, Lee N, Kim J, Jo Y. Spontaneous resolution of gallbladder hematoma in blunt traumatic injury: A case report. World J Clin Cases 2021; 9:8518-8523. [PMID: 34754862 PMCID: PMC8554416 DOI: 10.12998/wjcc.v9.i28.8518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/12/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We report a case of intragallbladder hematoma and biliary tract obstruction caused by blunt gallbladder injury. We report that the patient was safely treated by conservative treatment after the obstruction was resolved by endoscopic retrograde cholangiopancreatography (ERCP).
CASE SUMMARY A 67-year-old man was admitted via the emergency department due to complaints of right-sided abdominal pain that started 2 d prior. Four days prior to presentation, the patient had slipped, fallen and struck his abdomen on a motorcycle handle. His initial vital signs were stable. On physical examination, he showed right upper quadrant pain and Murphy’s sign, with decreased bowel sounds. Additionally, he had had a poor appetite for 4 d. He had been on aspirin for 2 years due to underlying hypertension. Initial simple radiography revealed a slight ileus. The laboratory findings were as follows: white blood cell count, 15.5 × 103/µL (normal range 4.8 × 103–10.8 × 103); hemoglobin, 9.4 g/dL; aspartate aminotransferase/alanine transferase, 423/348 U/L; total bilirubin/direct bilirubin, 4.45/3.26 mg/dL; -GTP , 639 U/L (normal range 5–61 U/L); and C-reactive protein, 12.32 mg/dL (0–0.3). Abdominal computed tomography showed a distended gallbladder with edematous wall change and a 55 mm × 40 mm hematoma. Dilatation was observed in both the intrahepatic and common bile duct areas. Antibiotic treatment was initiated, and ERCP was performed, with hemobilia found during treatment. After cannulation, the patient’s symptoms were relieved, and after conservative management, the patient was discharged with no further complications. After 1-month follow-up, the gallbladder hematoma was completely resolved.
CONCLUSION In the case of traumatic injury to the gallbladder, conservative treatment is feasible even in the presence of hematoma.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Dong-gu 61469, Gwangju, South Korea
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Sakharuk I, Martinez P, Laub M, Gani I, Saeed M. Anticoagulant-induced hemorrhagic cholecystitis with hemobilia after deceased donor kidney transplant and literature review. Int J Surg Case Rep 2021; 84:106027. [PMID: 34118559 PMCID: PMC8196047 DOI: 10.1016/j.ijscr.2021.106027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction and importance Hemobilia and hemorrhagic cholecystitis are uncommon causes of right upper quadrant abdominal pain. The development of intra-gallbladder and biliary bleeding has been primarily associated with abdominal trauma, malignancy, liver transplant, and iatrogenic injury to the biliary tree and vasculature. Spontaneous anticoagulant induced hemorrhagic cholecystitis and hemobilia are incredibly rare events and have only been documented by a handful of case reports. Case presentation A 55-year-old male who had recently undergone a deceased-donor kidney transplant was transferred to our academic institution for evaluation of subjective fever, right upper quadrant abdominal and back pain. The patient demonstrated localized tenderness in the right abdomen and was found to have hemorrhagic cholecystitis on imaging. He subsequently underwent urgent cholecystectomy and recovered without any subsequent complications. Clinical discussion Hemorrhagic cholecystitis and hemobilia are a rare cause of right-sided or generalized abdominal pain. Diagnosis is made primarily by pathognomonic findings on CT and US imaging. Prompt diagnosis is essential in preventing mortality and/or significant morbidity. The standard treatment consists of urgent/emergent cholecystectomy. Conclusion A rare sequelae of anticoagulant use, intra-biliary bleeding must be considered as a differential diagnosis in anticoagulated patients presenting with right upper quadrant abdominal pain.
Hemorrhagic cholecystitis is uncommon cause of right upper quadrant abdominal pain Spontaneous anticoagulant induced hemorrhagic cholecystitis have only been reported by a handful of case reports. Patients experiencing intra-gallbladder bleeding often present with symptoms similar to those seen in acute cholecystitis.
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Affiliation(s)
- Ilya Sakharuk
- Augusta University, Department of Surgery, United States of America
| | | | - Melissa Laub
- Augusta University, Department of Pharmacy, United States of America
| | - Imran Gani
- Augusta University, Department of Medicine, United States of America
| | - Muhammad Saeed
- Augusta University, Department of Surgery, United States of America.
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Zhang X, Zhang C, Huang H, Wang J, Zhang Y, Hu Q. Hemorrhagic cholecystitis with rare imaging presentation: a case report and a lesson learned from neglected medication history of NSAIDs. BMC Gastroenterol 2020; 20:172. [PMID: 32503437 PMCID: PMC7275556 DOI: 10.1186/s12876-020-01312-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/20/2020] [Indexed: 12/24/2022] Open
Abstract
Background Gallbladder carcinogenesis, frequently occurredin chronic cholecystitis patients, requires radical resection. We herein describe a hemorrhagic cholecystitis case that failed to be differentiated from gallbladder cancer preoperatively owing to the neglected medication history of long term oral nonsteroidal anti-inflammatory drugs (NSIADs) intake. Case presentation A 57-year-old Chinese female was admitted for right upper quadrant pain with the initial diagnosis of cholecystitis. Radiological studies were unable to exclude the differential diagnosis of suspected gallbladder cancer. During the scheduled radical resection of the suspected lesions, the gross dissection showed an interesting presentation of hemorrhagic cholecystitis, without any pathological evidence of malignancies. Additional postoperative investigation revealed a neglected medication history of long-term NSAIDs use. Conclusions This case suggests the importance of preoperative review of medication history and patient education on prescription drug abuse.
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Affiliation(s)
- Xin Zhang
- Department of Radiology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Chunjun Zhang
- Department of Surgery, Shengzhou People's Hospital, Shengzhou, 312400, China
| | - Haifeng Huang
- Department of Surgery, Shengzhou People's Hospital, Shengzhou, 312400, China
| | - Junsen Wang
- Department of Pathology, Shengzhou People's Hospital, Shengzhou, 312400, China
| | - Yun Zhang
- Department of Surgery, Shengzhou People's Hospital, Shengzhou, 312400, China.,Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China
| | - Qida Hu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.
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Ma Z, Xu B, Wang L, Mao Y, Zhou B, Song Z, Yang T. Anticoagulants is a risk factor for spontaneous rupture and hemorrhage of gallbladder: a case report and literature review. BMC Surg 2019; 19:2. [PMID: 30611267 PMCID: PMC6321697 DOI: 10.1186/s12893-018-0464-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 12/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background The spontaneous rupture of the gallbladder is extremely rare, majority of ruptures occur secondary to traumatic injuries. Here, we report a case of spontaneous rupture of the gallbladder with probably cause of oral anticoagulants. Case presentation A 51-year-old woman presented to the emergency room with sudden-onset severe abdominal pain, as well as hypotension and low level of hemoglobin. Abdominal computed tomography (CT) scan showed a 2.5 cm filling defect and discontinuity in the wall of the gallbladder body, and a massive hematocele in the abdominal cavity. Past medical history was significant for hypertension and had been taking daily aspirin for the past three years because of interventional surgery for cerebral aneurysms, but no history of recent abdominal trauma or past episodes of biliary colic. The patient underwent an urgent laparoscopic abdominal exploration and the gallbladder was removed. The pathology just showed chronic cholecystitis and the patient recovered well. Conclusion Long-term use of anticoagulants may increase the risk of gallbladder rupture and hemorrhage, which is a lethal condition. Rapid diagnosis and timely surgical intervention are the most important measures to treat the patient.
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Affiliation(s)
- Zhilong Ma
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bin Xu
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Long Wang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yukan Mao
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bo Zhou
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Zhenshun Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
| | - Tingsong Yang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Kwok A, Chern TY, Winn R. Acute cholecystitis and gallbladder perforation leading to massive haemoperitoneum in a patient taking rivaroxaban. BMJ Case Rep 2018; 2018:bcr-2018-226870. [PMID: 30373899 PMCID: PMC6214373 DOI: 10.1136/bcr-2018-226870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2018] [Indexed: 11/03/2022] Open
Abstract
We present the case of an 80-year old man taking rivaroxaban for atrial fibrillation who sustained massive intra-abdominal bleeding in the setting of acute cholecystitis. CT scan on admission revealed evidence of active bleeding into the gallbladder lumen and gallbladder perforation. Immediate resuscitation was commenced with intravenous fluids, antibiotics and blood products. Despite attempts to correct coagulopathy, the patient's haemodynamic status deteriorated and an emergency laparotomy was performed, with open cholecystectomy, washout and haemostasis. The patient had a largely uneventful recovery and was discharged on day 11 of admission. Patients with coagulopathies, whether pharmacological or due to underlying disease processes, are at very high risk of severe haemorrhagic complications and subsequent morbidity. As such, prompt recognition and operative management of haemorrhagic perforated cholecystitis is of crucial importance.
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Affiliation(s)
- Allan Kwok
- Department of Surgery, Wollongong Hospital, South Coast Mail Centre, New South Wales, Australia
| | | | - Robert Winn
- Department of Surgery, Wollongong Hospital, South Coast Mail Centre, New South Wales, Australia
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Kinnear N, Hennessey DB, Thomas R. Haemorrhagic cholecystitis in a newly anticoagulated patient. BMJ Case Rep 2017; 2017:bcr-2016-214617. [PMID: 28404563 DOI: 10.1136/bcr-2016-214617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 74-year-old man undergoing rehabilitation after pneumonia developed right upper quadrant abdominal pain. Five days earlier he had been commenced on apixaban for a new diagnosis of atrial fibrillation. Ultrasound and CT scans revealed an acalculous grossly thickened gallbladder, with high attenuation non-echogenic material both within and surrounding the structure. Active contrast extravasation was seen at the neck. On laparotomy, a perforated internally bleeding gallbladder containing a single calculus was found, with significant free blood within the abdomen. After cholecystectomy, the patient recovered slowly in hospital before nursing home placement.
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Affiliation(s)
- Ned Kinnear
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia .,Department of General Surgery, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Derek Barry Hennessey
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia.,Department of Urology, Craigavon Area Hospital, Portadown, UK
| | - Rebecca Thomas
- Department of General Surgery, Lyell McEwin Hospital, Elizabeth Vale, Australia
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Mechera R, Graf L, Oertli D, Viehl CT. Gallbladder perforation and massive intra-abdominal haemorrhage complicating acute cholecystitis in a patient with haemophilia A. BMJ Case Rep 2015; 2015:bcr-2014-205971. [PMID: 25935908 DOI: 10.1136/bcr-2014-205971] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We present an unusual case of a 32-year-old man with haemophilia A, who sustained massive, haemodynamically significant intra-abdominal bleeding from a perforated gallbladder wall and from the greater omentum as a complication of acute ulcerophlegmonous and haemorrhagic cholecystitis. Recombinant coagulation factor VIII was given and an emergency laparotomy was performed, with open cholecystectomy and haemostasis. Coagulation factor VIII was given for a further 2 weeks postoperatively, and the patient was discharged in good condition. In most published cases of haemorrhagic cholecystitis, the haemoperitoneum arises via transhepatic perforation; in this case, there was a free rupture into the peritoneal cavity. Patients with coagulopathies may have severe haemorrhagic complications and therefore need interdisciplinary management before, during and after surgery. Replacement therapy with factor concentrates should be initiated at once, and early surgery for gallbladder disease should be considered.
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Affiliation(s)
- Robert Mechera
- Department of Surgery, University of Basel, Basel, Switzerland
| | - Lukas Graf
- Department of Haematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Oertli
- Department of Surgery, University of Basel, Basel, Switzerland
| | - Carsten T Viehl
- Department of Surgery, Spitalzentrum Biel, Biel, Switzerland
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Hamada T, Yasunaga H, Nakai Y, Isayama H, Horiguchi H, Fushimi K, Koike K. Severe bleeding after percutaneous transhepatic drainage of the biliary system: effect of antithrombotic agents--analysis of 34 606 cases from a Japanese nationwide administrative database. Radiology 2014; 274:605-13. [PMID: 25203133 DOI: 10.1148/radiol.14140293] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the relationship between antithrombotic agents (antiplatelet agents and anticoagulants) and severe bleeding after percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction, or cholecystostomy for acute cholecystitis. MATERIALS AND METHODS This retrospective study was institutional review board-approved, and patient consent was waived. Between July 2007 and March 2012, 34 606 patients who underwent PTBD (23 375 patients) or cholecystostomy (11 231 patients) were identified in the Diagnosis Procedure Combination database covering 1119 Japanese hospitals. The association between oral administration of antithrombotic agents prior to the procedure and severe bleeding was evaluated, with adjustment for other potential risk factors, such as age, chronic renal failure, liver cirrhosis, and procedure type. Users of antithrombotic agents were categorized as the continuation group, when they took these agents on the procedure day, or as the discontinuation group, when none were taken. Severe bleeding was defined as bleeding which required red blood cell transfusion or transcatheter arterial embolization within 3 days of the procedure. Univariate and multivariate logistic regression models fitted with generalized estimating equations were performed to evaluate the effect of antithrombotic agents on the bleeding complication. RESULTS Overall, 780 of 34 606 patients (2.3%) experienced severe bleeding. In the multivariate model, continuation of antiplatelet agents was significantly associated with severe bleeding versus nonuse (odds ratio [OR], 1.87; 95% confidence interval [CI]: 1.14, 3.05; P = .013), whereas discontinuation of antiplatelet agents showed no association (OR, 0.92; 95% CI: 0.70, 1.20; P = .517). The effect of neither continuation nor discontinuation of anticoagulants on severe bleeding was significant. Other significant risk factors for bleeding included older age, chronic renal failure, liver cirrhosis, academic hospital, and PTBD. CONCLUSION The continuation of antiplatelet agents can increase severe bleeding after percutaneous transhepatic drainage, whereas the effect of continuation of anticoagulants was inconclusive.
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Affiliation(s)
- Tsuyoshi Hamada
- From the Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan (T.H., Y.N., H.I., K.K.); Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan (H.Y.); Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan (H.H.); and Department of Health Care Informatics, Tokyo Medical and Dental University, Tokyo, Japan (K.F.)
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