GuidelinesGuideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures
Introduction
Anticoagulation therapy with warfarin is used to reduce the risk of thromboembolic events in patients with certain cardiovascular conditions, deep vein thrombosis (DVT), and hypercoagulable states. Anticoagulation therapy complicates the management of gastrointestinal bleeding. Interruption of anticoagulation therapy may be desirable for some patients undergoing endoscopic procedures. When preparing for an endoscopic procedure on an anticoagulated patient considerations include (1) the risk of complications of the underlying gastrointestinal disorder related directly to anticoagulation therapy; (2) bleeding related to an endoscopic intervention carried out in the setting of anticoagulation; and (3) a thromboembolic event related to interruption of anticoagulation therapy. Additional considerations include the utilization of resources for hospitalization, parenteral anticoagulation therapy, and laboratory tests used to monitor and document adjustment of anticoagulation therapy.
This guideline addresses the management of patients undergoing endoscopic procedures who are on either anticoagulation therapy or aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS). First, the endoscopic management of acute gastrointestinal bleeding in therapeutically anticoagulated patients is discussed. Second, the risk of bleeding related to endoscopic interventions is considered. Third, the risk of thromboembolic events associated with interrupting anticoagulation therapy is discussed. Management schemes for patients on long-term anticoagulation therapy are proposed. Last, the risk of bleeding related to the use of aspirin or other NSAIDS in the periendoscopic period is reviewed and recommendations for management are provided.
Section snippets
Acute gastrointestinal hemorrhage in the anticoagulated patient
The most common site of significant bleeding in patients receiving oral anticoagulation therapy is the gastrointestinal tract.1 A history of prior gastrointestinal bleeding, but not a history of peptic ulcer disease alone, is associated with an increased risk of major gastrointestinal hemorrhage during warfarin therapy (30% at 3 years versus 5% in those with no prior bleeding history).2 The risk of gastrointestinal bleeding is also increased when the international normalized ratio (INR) is
Recommendations
The decision to reverse anticoagulation, risking thromboembolic consequences, must be weighed against the risk of continued bleeding by maintaining the anticoagulated state. The degree of reversal of anticoagulation should be individualized. A supratherapeutic INR may be treated with fresh frozen plasma. In one series, correction of the INR to 1.5 to 2.5 allowed successful endoscopic diagnosis and therapy at rates comparable with those achieved in nonanticoagulated patients.3 In contrast to the
Procedure risks
Endoscopic procedures vary in their potential to produce significant or uncontrolled bleeding. Low-risk procedures include diagnostic esophagogastroduodenoscopy (EGD), flexible sigmoidoscopy and colonoscopy with or without biopsy, diagnostic endoscopic retrograde cholangiopancreatography (ERCP), and biliary stent insertion without endoscopic sphincterotomy, endosonography (EUS), and push enteroscopy. High-risk procedures include those associated with an increased risk of bleeding such as
References (29)
- et al.
Nd:YAG laser photocoagulation in colorectal adenoma. Evaluation of its safety, usefulness and efficacy
Gastroenterology
(1986) - et al.
Pallia five Nd:YAG laser therapy for cancer of the esophagus and gastroesophageal junction: impact on quality of remaining life
Gastrointest Endosc
(1988) - et al.
Endoscopic sphincterotomy complications and their mangement: An attempt at consensus
Gastrointest Endosc
(1991) Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism
Lancet
(1992)- et al.
Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDs
Gastrointest Endosc
(1994) - et al.
Acute gastrointestinal haemorrhage in patients treated with anticoagulant drugs
Gut
(1995) - et al.
Anticoagulant related bleeding: clinical epidemiology, prediction and prevention
Am J Med
(1993) - et al.
Acute gastrointestinal haemorrhage in anticoagulated patients: diagnosis and response to Endoscopic treatment
Gut
(1994) - et al.
The mangement of patients on chronic coumadin therapy undergoing subsequent surgical procedures
Am Surg
(1994) - et al.
Gostout CJ. The role of withdrawing chronic anticoagulation because of acute GI bleeding
Am J Gastroenterol
(1996)
Colonoscopy
CA Cancer J Clin
Endoscopic gastric polypectomy
May Clin Proc
Thromboembolic and bleeding complications in patients with mechanical heart valve prosthesis
Circulation
Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves
Chest
Cited by (307)
Endoscopic Evaluation and Management of Pancreaticobiliary Disease
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume SetOne-Year Survival is Not Affected by Gastrointestinal Bleeding After Percutaneous Coronary Interventions
2017, American Journal of the Medical SciencesManaging antithrombotic agents during endoscopy
2016, Best Practice and Research: Clinical GastroenterologyHow much does the specialist know about cardiogastroenterology?
2018, Revista de Gastroenterologia de Mexico