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Gastrointestinal Endoscopic Interventions During Antithrombotic Therapy: A Comprehensive Review of Bleeding Risk and
Omar Alkasabrah1, Pankti Maniyar2, EzzElDien A Ibrahim3
1From the Department of Internal Medicine, New York Medical College at Landmark Medical Center, Woonsocket, RI.
Insights
Managing antiplatelet and anticoagulant therapy during endoscopy is crucial. Low-risk procedures can often proceed without interruption, while high-risk interventions require careful risk assessment for bleeding versus clotting.
Area of Science:
- Gastroenterology
- Cardiology
- Pharmacology
Background:
- Increasing use of antiplatelet and anticoagulant therapies presents challenges in periprocedural management for endoscopic procedures.
- Balancing procedural bleeding risk against thromboembolic risk is critical when managing patients on antithrombotic agents undergoing endoscopy.
Purpose of the Study:
- To review current guidelines and evidence for managing antiplatelet and anticoagulant therapy during diagnostic and therapeutic endoscopy.
- To provide guidance on continuing, interrupting, or bridging antithrombotic therapy based on procedure risk and patient factors.
Main Methods:
- Review of current society guidelines.
- Analysis of evidence from randomized trials, cohort studies, and meta-analyses.
- Evaluation of risks associated with different endoscopic procedures and antithrombotic agents.
Main Results:
- Diagnostic endoscopy with biopsy is low-risk and often requires no interruption of antithrombotics.
- High-risk therapeutic endoscopy (e.g., polypectomy, EMR, ESD) carries increased bleeding risk, especially with anticoagulants or multiple agents.
- Cold snare polypectomy shows promise as a bleeding-sparing technique for small polyps in anticoagulated patients.
Conclusions:
- Guidelines support aspirin continuation, temporary P2Y12 inhibitor interruption for high-risk procedures, brief direct oral anticoagulant interruption, and avoidance of routine heparin bridging.
- Antithrombotic management must be individualized based on procedure type, bleeding risk, and thromboembolic risk.
- Cold snare polypectomy is a recommended technique to minimize bleeding during colorectal polyp removal in patients on antithrombotic therapy.
Abstract:
The increasing use of antiplatelet and anticoagulant therapy has made periprocedural management a central issue in patients undergoing diagnostic and therapeutic endoscopy. Upper endoscopy and colonoscopy are commonly performed in patients receiving aspirin, P2Y12 receptor inhibitors, warfarin, or direct oral anticoagulants, and the clinical decision to continue, interrupt, or bridge therapy requires balancing procedure-related bleeding against thromboembolic risk. Diagnostic esophagogastroduodenoscopy and colonoscopy with mucosal biopsy are generally low-risk procedures and can usually be performed without interruption of most antithrombotic agents. In contrast, colonoscopic polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and other advanced therapeutic interventions carry a higher delayed bleeding risk, particularly in patients receiving anticoagulants or multiple antithrombotic drugs. Current society guidelines generally support continuation of aspirin, temporary interruption of P2Y12 receptor inhibitors for elective high-risk procedures when thrombotic risk permits, brief interruption of direct oral anticoagulants for high-risk interventions, and avoidance of routine heparin bridging except in selected patients with very high thromboembolic risk. Evidence from randomized trials, cohort studies, and meta-analyses supports cold snare polypectomy as a bleeding-sparing technique for small colorectal polyps, especially in anticoagulated patients.
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