Elsevier

Gastrointestinal Endoscopy

Volume 70, Issue 6, December 2009, Pages 1060-1070
Gastrointestinal Endoscopy

Guideline
Management of antithrombotic agents for endoscopic procedures

https://doi.org/10.1016/j.gie.2009.09.040Get rights and content

Section snippets

Procedure risks

Endoscopic procedures vary in their potential to produce significant or uncontrolled bleeding (Table 3). Low-risk procedures include all diagnostic procedures including those with mucosal biopsy5, 6 and ERCP without sphincterotomy,7, 8 diagnostic balloon-assisted enteroscopy,9 and EUS without FNA or Tru-Cut needle biopsy.10 Higher-risk procedures include those associated with an increased risk of bleeding, such as endoscopic polypectomy,11, 12 therapeutic balloon-assisted enteroscopy,9, 13

Diagnostic endoscopy

Although aspirin has been shown to prolong bleeding times as long as 48 hours after ingestion,26, 27 there are no clinical trials demonstrating an increased incidence of bleeding in patients who have undergone upper or lower endoscopy with and without biopsy while taking aspirin or clopidogrel. Moreover, there is evidence that continuing therapeutic anticoagulation with warfarin during the periendoscopic period has a low risk of bleeding in such low-risk procedures. A retrospective study by

Stopping or reversing antithrombotic agents in the acutely bleeding patient

The decision to stop, reduce, and/or reverse antithrombotic therapy, risking thromboembolic consequences, must be weighed against the risk of continued bleeding by maintaining antithrombotic agents, and this should be individualized. According to guidelines from the American College of Chest Physicians, it is recommended that warfarin be held and vitamin K be given (10 mg by slow intravenous administration) in all cases of serious or life-threatening bleeding and that fresh frozen plasma (FFP),

Elective endoscopy in the patient with a vascular stent

The use of DAT, such as aspirin and clopidogrel, in the care of patients with a vascular stent, acute coronary syndrome (ACS), and cerebrovascular disease has become increasingly commonplace in clinical practice today. According to current guidelines from the ACC and the AHA, DAT is recommended for a minimum of 1 month after placement of a bare metal stent and ideally for 12 months after placement of a DES or in patients who have undergone percutaneous coronary intervention who are not at high

First page preview

First page preview
Click to open first page preview
View PDF

References (79)

  • S. Friedland et al.

    Colonoscopy with polypectomy in anticoagulated patients

    Gastrointest Endosc

    (2006)
  • D.A. Howell et al.

    Use of hemostatic clips in patients undergoing colonoscopy in the setting of Coumadin antithrombotic therapy

    Gastrointest Endosc

    (2006)
  • E. Masci et al.

    Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

    Am J Gastroenterol

    (2001)
  • P.B. Cotton et al.

    Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years

    Gastrointest Endosc

    (2009)
  • G.D. Schapiro et al.

    Complications of percutaneous endoscopic gastrostomy

    Gastrointest Endosc Clin N Am

    (1996)
  • N. Seshadri et al.

    The clinical challenge of bridging antithrombotic with low-molecular-weight heparin in patients with mechanical prosthetic heart valves: an evidence-based comparative review focusing on antithrombotic options in pregnant and nonpregnant patients

    Am Heart J

    (2005)
  • U.R. Elkayam

    Anticoagulation in pregnant women with prosthetic heart valves: a double jeopardy

    J Am Coll Cardiol

    (1996)
  • K.C. Lai et al.

    Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications

    Clin Gastroenterol Hepatol

    (2006)
  • K. Ananthasubramaniam et al.

    How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage?

    Chest

    (2001)
  • A.E. Abbas et al.

    Incidence and prognostic impact of gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction

    Am J Cardiol

    (2005)
  • M.S. Cappell et al.

    Safety and efficacy of esophagogastroduodenoscopy after myocardial infarction

    Am J Med

    (1999)
  • M.S. Cappell

    Safety and efficacy of colonoscopy after myocardial infarction: an analysis of 100 study patients and 100 control patients at two tertiary cardiac referral hospitals

    Gastrointest Endosc

    (2004)
  • G.H. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • C.P. Choudari et al.

    Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment

    Gut

    (1994)
  • E.J. Williams et al.

    Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study

    Endoscopy

    (2007)
  • P.B. Mensink et al.

    Complications of double balloon enteroscopy: a multicenter survey

    Endoscopy

    (2007)
  • M.B. Mortensen et al.

    Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography

    Endoscopy

    (2005)
  • J. Waye

    Colonoscopy

    CA Cancer J Clin

    (1992)
  • S.G. Remine et al.

    Endoscopic gastric polypectomy

    Mayo Clin Proc

    (1981)
  • A. May et al.

    Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations

    Am J Gastroenterol

    (2007)
  • V.V. Singh et al.

    Efficacy and safety of endoscopic balloon dilation of symptomatic upper and lower gastrointestinal Crohn's disease strictures

    J Clin Gastroenterol

    (2005)
  • J. Solt et al.

    Long-term results of balloon catheter dilation for benign gastric outlet stenosis

    Endoscopy

    (2003)
  • J.A. DiSario et al.

    Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction

    Am J Gastroenterol

    (1994)
  • A. Horiuchi et al.

    Prospective randomized trial comparing the direct method using a 24 Fr bumper-button-type device with the pull method for percutaneous endoscopic gastrostomy

    Endoscopy

    (2008)
  • M. Al-Haddad et al.

    The safety of fine-needle aspiration guided by endoscopic ultrasound: a prospective study

    Endoscopy

    (2008)
  • S.C. Cannegieter et al.

    Thromboembolic and bleeding complications in patients with mechanical heart valve prosthesis

    Circulation

    (1994)
  • R.D. Stein et al.

    Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves

    Chest

    (1992)

  • Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials

    Arch Intern Med

    (1994)
  • R.G. Hart et al.

    Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators

    Stroke

    (1999)

    • Cited by (0)

    This document is a product of the Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. This document was reviewed and endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons Guidelines Committee and Board of Governors.

    View full text
    Copyright © 2009 Published by Mosby, Inc.