Gastroenterology and Hepatology


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Antithrombotics in Endoscopy:


  1. Bleeding related solely to antithrombotic
  2. Bleeding related to an endoscopic intervention performed in the setting of antithrombotic use
  3. Thromboembolic event related to interruption of antithrombotic therapy


Low risk of bleeding during procedure:


High risk of bleeding during procedure:


Low risk of thromboembolic event:


High risk of thromboembolic event:


Rate of major embolism in patients with mechanical valves


AF which is nonanticoagulated has an annual stroke rate of 4.5%



Risk of continuing antiplatelets:

Diagnostic endoscopy:

No bleeding in endoscopy with or without biopsy while taking either ASA of clopidogrel

Even warfarin is safe for low risk endoscopy with or without mucosal biopsy in OGDS and Colonoscopy

Colonoscopic polypectomy:

ASA/NSAID has low post polypectomy bleeding

Warfarin within 1 week has a higher risk of bleeding which polypectomy clip doesn’t prevent.

Sphincterotomy (0.3 – 2%) and PEG (2.5% bleeding without antithrombotics):

Anticoagulation within 3 days increases risk of bleeding

ASA / NSAID for 7 days hasn’t been shown to reduce the risk of bleeding


Risk of stopping antiplatelets:

Absolute risk of an embolic event whom anticoagulation is stopped 4 – 7 days is 1%

If antithrombotics are temporary and the procedure can be delayed, it should be delayed till after stopping antithrombotics


Reinitiation of antithrombotics:

No consensus on the optimal timing of restarting antithrombotics

If low risk, attempt to restart within 24 hours while if high risk, to restart as soon as bleeding stability allows



No prospective data to determine safe level of INR for endoscopic therapy.

INR < 2.5 seems to be safe

Restarting antiplatelets within 1 week increases bleeding by 2x (19% vs 11%) but the risk of mortality at 2 months improves markedly (1.7% vs 14.5%)



Minimum DAT for BMS is 1 month and DES is 1 year

ASA alone has more safety data than Clopidogrel alone once DAT period over.

GIB in ACS: 4 – 7 fold mortality than ACS alone

Endoscopy risk is up to 12% on same day of ACS, usually 1 %

GIB leading to ACS has a higher risk of needing endoscopic treatment compared with ACS followed by GIB


Antithrombotics in elective setting



Antithrombotics in emergency setting




edited 16th July 2010