Aspirin/clopidogrel/ticagrelor

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a case series, a 59-year-old woman and a 72-year-old man were described, who developed diffuse ooze or bleeding during treatment with aspirin, clopidogrel or ticagrelor for myocardial infarction [routes and dosages not stated].

The woman presented with complaints of abdominal pain, bloating and worsening diarrhoea for the last 4 years. Her loose motions were often mixed with blood. Her situation had deteriorated over the last 4 months. She had also suffered from myocardial infarction 1 month prior to the presentation and had started receiving ticagrelor and aspirin dual therapy. She had history of radiotherapy treatment for anal cancer 10 years before. Her medical history included rectovaginal fistula, diverticulosis and cholecystectomy. During admission, she had raised inflammatory markers and tachycardia. She was treated with unspecified steroids and her condition improved. However, she had episodic crampy abdominal pain and persisting loose motions. She was started rescue therapy with infliximab. Subsequently, she underwent several diagnostic tests revealing mural thickening of the transverse and descending colon with pericolic fat stranding, increased periadventitial fat stranding , colonic dilatation and intrahepatic portal venous air. Therefore, she was scheduled for surgery without stopping the dual therapy. She received packed cells and cryoprecipitate prior to induction. Toxic megacolon with ischaemic patches revealed signs of impending perforation noted during laparotomy. She underwent a total colectomy with ileostomy. After meticulous haemostasis thorough washout was performed and drains were left in hepatorenal pouch and pelvis. During the surgery, she had diffuse ooze from abdominal cavity. Postoperatively, the dual therapy was continued with level 2 care. She had decrease in haematocrit with 950mL of drain output in the first 4 hours. She developed volume responsive hypotension needing unspecified inotropic support. She was treated with platelet rich concentrate, packed cells and cryoprecipitate. She had significant reduction in drain output within 6 hours of surgery. She had continuous improvement even after wound infection [aetiology not stated] and was discharged by 7 weeks after protracted recovery. Histopathology revealed features of indeterminate colitis with focal perforations.

The man presented with painful, irreducible and complete right sided inguinoscrotal hernia. He had diabetes and was on haemodialysis with limited walking ability. He developed myocardial infarction 5 months prior to the presentation and started receiving clopidogrel and aspirin dual therapy. He also had chronic heart failure. He was scheduled for surgery with continuing the dual therapy. Subsequently, he underwent the surgery and received platelet rich concentrate during wound closure. Postoperatively, he was successful extubated with bedside haemofiltration and received Level 2 care. On day 2 of the surgery, he was able to eat and drink and was back on regular haemodialysis from the following day. The dual antiplatelet therapy was temporarily stopped from the second day due to fresh bleeding from around drain site. The dual therapy was restarted after 3 days. On day 10 of the surgery, he opened his bowels, but started developing shortness of breath from thirteenth day onwards. He tested positive for COVID-19. He was transferred to tertiary care unit. Though he recovered well from the surgery apart from wound infection [aetiology not stated], he died due to his medical problems later.