Very important topic for every gastroenterologist

1. Attia Salman, Msc
Gastroentrology department
Nasser Institute Hospital

3. Is that important to gastroentrologists ? Why?
Sure, it is a daily problem face all of us , many
questions need to be answered :
• Which procedures needs anticoagulant and/or
antithrombotic stopping ?
• Which patients are risky for thrmbosis?
• When to stop?
• When to reintroduce ?

4. •A : Elective endoscopy(1)
1- British Society of Gastroenterology (BSG)
And European Society of Gastrointestinal Endoscopy (ESGE)
guidelines

5. Endoscopic procedures are
classified to :
Low risk procedure :
• Diagnostic procedures +/・biopsy.
• Biliary or pancreatic stenting.
• Diagnostic EUS.
• Device-assisted enteroscopy without
polypectomy.

6. High risk procedures
• Polypectomy
• ERCP with sphincterotomy
• Ampullectomy
• EMR (Endoscopic mucosal resection)
• ESD (Endoscopic submucosal dissection)
• Dilation of strictures
• Therapy of varices
• PEG (Percutaneous endoscopic gastrostomy)
• EUS with FNA
• Oesophageal, enteral or colonic stenting

7. Patients on antiplatelets are classified
based on the risk of thrombosis:
Low risk
• Ischaemic heart disease
without coronary stent
• Cerbrovascular disease
• Peripheral vascular
disease
High risk
• Drug eluting coronary artery
stents within 12 months of
placement
• Bare metal coronary artery
stents within 1 month of
placement

8. Patients on antiplatlets and undergoing
low endoscopic risk procedures
• Aspirin : continue.
• clopidogrel, prasugrel or ticagrelor: continue.

9. Patients on antiplatlets undergoing high
risk endoscopic procedures
• Aspirin : For all endoscopic procedures we
recommend continuing aspirin
with the exception of:
• ESD.
• large colonic EMR (>2cm).
• upper gastrointestinal EMR.
• ampullectomy.
NB:In these cases consultation of cardiologist
is very important.

10. Patients on antiplatlets undergoing high risk
endoscopic procedures and on Clopidogrel.
Low risk of thromosis
• Stop clopidogrel 5
days before
endoscopy.
High risk of
thrombosis
• Consult cardiology

11. Types of anticoagulants and its duration of
actoion.
Specific agent(s) Duration of action
Heparin ( UFH) IV 2-6 hours , SQ 12-24 hours
LMWH( low molecular weigt
heparin): enoxaparin
,dalteparin
24 hours
Fondaparinux (Arixtra) 36-48 hours
Warfarin (Coumadin) 5 days
DOAC ( direct oral anticoaguant)
▪Dabigatran (Pradaxa)
▪Rivaroxaban (Xarelto)
▪Apixaban , Edoxaban
About 2 days in patient with
normal creatinine clearance.

12. Patients on warfarin are classified based
on the risk of thrombosis:
High risk
• Prosthetic metal heart
valve in mitral
position
• Prosthetic heart valve
and atrial fibrillation
• Atrial fibrillation and
mitral stenosis*
• <3 months after
venous
thromboembolism
Low risk
• Prosthetic metal heart
valve in aortic position
• Xenograft heart valve
• Atrial fibrillation
without valvular disease
• >3 months after venous
thromboembolism
• Thrombophilia
syndromes (discuss with
haematologist)

13. Patients on oral anticoagulants and undergoing
low risk endoscopic procedure.
Warfarin
• Continue warfarin
Check INR during the week
before endoscopy:
• If INR within therapeutic
range continue usual
daily dose ・
• If INR above therapeutic
range but <5 reduce daily
dose until INR returns to
therapeutic range.
DOAC
• Omit DOAC on
morning of
procedure.

14. Patients on oral anticoagulants and undergoing
high risk endoscopic procedure.
Warfarin
• Low risk of thrombosis :
stop warfarin 5 days
before operation ( INR <
1.5 ).
High risk of thrombosis :
• Stop warfarin 5 days
before endoscopy.
• Start LMWH 2 days after
stopping warfarin.
• Give last dose of LMWH
≥24 hours before
procedure.
DOAC
• Stop 2 days before
procedure.
• NB: if there is renal
impairment , consult
hematologist .

15. When to reintroduce
anticoagulants?
warfarin
• Restart warfarin
evening of procedure
with usual daily dose.
• NB: in high risky
patients Continue
LMWH until INR
becomes adequate
DOAG
• The anti thrombotic
effect is restored
within 3 hours of
intake , so if intensive
maneuver was done
and a high risk of
bleeding present , it is
recommended to
delay onset 24-
48hours.

16. •B : Emergent
endoscopy in acute
bleeding. (2)
2 - American So ciety for Gastrointestinal Endoscopy (ASGE )
guidelines.

17. Patients on anticoagulants:
• Consult cardiologist.
• Hold anticoagulants
• In severe bleeding due to vitamin K antagonist, reverse the
effect of anticoagulant by :
I. 4-factors PCC + vitamin K or,
II. Fresh frozen plasma.
• In patients on dabigatran (Pradaxa) , hemodialysis could be
done
• endoscopic therapy not be delayed in patients with serious GI
bleeding and an INR < 2.5.
• After successful endoscopic hemostasis,patients who require
anticoagulants can be given unfractionated heparin.
PCC : prothrombin complex concentrate.

18. Patients on antiplatelets
.
• Consult cardiologist especially in patients with
high risk of thrombosis,
• In patients with severe bleeding hold the agents
and ,or administration of platelets.
• For patients who develop ASA-related peptic
ulcer disease bleeding:
• resumption of ASA with concurrent proton pump
inhibitor therapy is superior to switching to
clopidogrel alone for the prevention of recurrent
GI bleeding.

19. Thank you