Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

Abstract

The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).

Keywords: Endoscopy; Anticoagulants; Antiplatelets; Antithrombotics; Bleeding; Gastrointestinal

Core Tip: The current position statements and guidelines from the major gastroenterology societies have provided endoscopists with an evidenced-based systematic approach to pre, peri and post-operative management of patients on anticoagulant and/or antiplatelet therapy, in the context of both low and high-risk endoscopic procedures. While there is sufficient evidence on the index bleeding risk for common endoscopic procedures in the absence of anticoagulant and/or antiplatelet use, the evidence surrounding the bleeding risk on anticoagulant and/or antiplatelet therapy is variable among different publications and is still evolving. In this review, we have summarised the available evidence, provided an overview, and described our recommended practical approach to anticoagulant and/or antiplatelet management in common endoscopic procedures. Finally, we have compared our recommendations against the current guidelines from the major gastroenterology societies to assimilate a new working reference, and to highlight any knowledge gaps and directions for future research.