This document discusses guidelines for managing anticoagulant and antiplatelet medications before and after gastrointestinal endoscopic procedures. It addresses which procedures require stopping medications, how to classify patient thrombosis risk, when to stop and restart medications, and special considerations for emergent bleeding situations. Key points include classifying endoscopic procedures and patient thrombosis risk as low or high, recommendations to stop or continue various medications before low-risk versus high-risk procedures, and guidance on reversing anticoagulation effects or providing alternate medications for emergency bleeding situations.

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