Periendoscopic Period Research Articles

Reproducibility of the AGREE II Tool for Assessing the Methodological Quality of Clinical Practice Guidelines for the Management of Antithrombotic Agents in Patients Undergoing GI Endoscopy.

Clinical practice guidelines (CPGs) exist for the management of antithrombotic agents in the periendoscopic period; however, their methodological qualities vary. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool has been validated for the assessment of the methodological quality of CPGs; however, its reproducibility has not been assessed. The goal of this study was to assess the reproducibility of the AGREE II tool for CPGs published within the last 6 years for the management of antithrombotic agents in the periendoscopic period. A systematic search of PubMed and Embase databases was performed to identify eligible CPGs published between January 1, 2016 and April 14, 2022. The quality of the CPG was independently assessed by 6 reviewers using the AGREE II instrument. The reproducibility was summarized as weighted κ statistic and intraclass correlation coefficient using the SPSS statistical analysis package. The search yielded 343 citations with 7 CPGs from Europe, Asia, and the United States included in the critical appraisal. The overall mean weighted κ score across all guidelines was 0.300 (range, 0.093 to 0.384) indicating a fair agreement. The overall intraclass correlation coefficient was 0.462 (range, 0.175 to 0.570) for single measures and 0.837 (range, 0.560 to 0.888) for average measures indicating moderate reliability. Our study shows only a fair overall interobserver agreement in the methodological quality of the included CPGs. The results suggest the need for education and training of CPG raters to enhance the application of the AGREE II tool to improve its reproducibility.

Top tips on the management of antithrombotic agents in the periendoscopic period

Top tips on the management of antithrombotic agents in the periendoscopic period

A systematic critical appraisal of clinical practice guidelines of antithrombotic agents in gastrointestinal endoscopy using the AGREE II tool.

The quality of clinical practice guidelines (CPGs) for the management of antithrombotic agents in patients undergoing gastrointestinal (GI) endoscopy has not been systematically appraised. The goal of this study was to evaluate the methodological quality of CPGs for the management of antithrombotic agents in periendoscopic period published within last 6years. A systematic search of PubMed and Embase databases was performed to identify eligible CPGs published between January 1, 2016, and April 14, 2022, addressing the management of antithrombotic agents in the periendoscopic period. The quality of the CPG was independently assessed by six reviewers using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Domain scores were considered of sufficient quality when >60% and of good quality when >80%. The search yielded 343 citations, of which seven CPGs published by the gastroenterology associations in Asia (n=3), Europe (n=2), and North America (n=2) were included for the critical appraisal. The overall median score for the AGREE II domains was 93% (interquartile range [IQR] 11%) for scope and purpose, 79% (IQR 61%) for stakeholder involvement, 79% (IQR 36%) for rigor of development, 100% (IQR 14%) for clarity of presentation, 32% (IQR 36%) for applicability, 93% (IQR 29%) for editorial independence, and 86% (IQR 29%) for overall assessment. The findings show that the overall methodological quality of the CPGs for the management of antithrombotic agents in the periendoscopic period varies across the domains. There is significant scope for improvement in the methodological rigor and applicability of CPGs.

The Impact of Frailty on ERCP-Related Adverse Events: Findings From a National Cohort

Background and AimsEndoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that has evolved from being primarily diagnostic to predominantly therapeutic, leading to an increased potential for ERCP-related adverse events. Frailty is an independent predictor of adverse outcomes, and its impact on ERCP-related outcomes requires investigation. This study evaluated the impact of frailty on ERCP-related adverse events. MethodsThe National Inpatient Sample from 2016 to 2019 was used to identify adult patients who underwent ERCP. Frailty was defined using the Frailty Risk Score. Outcomes were categorized into procedure-related adverse events, sedation-related adverse events, and hospitalization outcomes. Multivariate linear or logistic regression was used as appropriate. Stata, version 14.2, was used to perform analyses considering a 2-sided P < 0.05 to be statistically significant. ResultsAmong a total of 693,730 ERCPs performed, 870,30 (12.54%) were frail. Frail patients had higher odds of procedure-related adverse events, including hemorrhage (9.1/1000 vs 4.9/1000) and duodenal perforation, but not post-ERCP pancreatitis, bile duct perforation, cholecystitis, and cholangitis. Frailty imparted a higher risk of sedation-related respiratory failure, aspiration pneumonia, and the requirement of intubation and mechanical ventilation. Inpatient mortality was higher among frail patients (4.54% vs 1.03%), and they had prolonged hospital stays and higher hospitalization costs. ConclusionFrailty is associated with worse outcomes in patients undergoing ERCP, with higher risks of hemorrhage and sedation-related adverse events, in addition to increased resource utilization. Therefore, the findings of this study suggest strict adherence to guidelines governing anticoagulant management during the peri-endoscopic period, and sedative administration should be carefully monitored. Preprocedural optimization measures and diligent monitoring can minimize resource utilization and decrease periprocedural morbidity.

Management Of Therapy of Anticoagulants and Antiplatelets in Acute Gastrointestinal Bleeding and In the Periendoscopic Period

Management of anticoagulant and antiplatelet therapy is a common clinical problem in case of urgent or elective gastrointestinal endoscopic procedures. Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. It’s recommended temporary interruption of anticoagulants in clinically significant gastrointestinal bleeding. For the antiplatelet therapy the decision is when to stop and restart the therapy, depending on whether it’s for primary or secondary cardiovascular prevention. Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. It’s recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures with high risk for bleeding and to consider the use of “bridging” therapy with LWMH for patients on vitamin K antagonists who are at high thrombotic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore collaboration with a cardiologist is of great importance, at least for some patients.

S622 Methodological Quality of Clinical Practice Guidelines for the Management of Antithrombotic Agents in Patients Undergoing GI Endoscopy: A Systematic Critical Appraisal Using the AGREE II Tool

Introduction: Several published clinical practice guidelines (CPGs) exist for the management of antithrombotic agents in patients undergoing GI endoscopy. However, to date, the quality of such CPGs has not been systematically appraised. The goal of this study was to identify and evaluate the quality of CPGs for the management of antithrombotic agents in peri endoscopic period published within last 6 years. Methods: A systematic search of PubMed and Embase database was performed to identify eligible CPGs. Any CPGs published between January 1, 2016 and April 14, 2022 addressing management of antithrombotic agents in patients undergoing GI endoscopy were eligible. The Canadian Agency for Drugs and Technologies in Health (CADTH) broad filter for the CPG terms was used since it is the most sensitive filter. The quality of the CPGs was independently assessed by five reviewers using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. Domain scores were considered of sufficient quality when >60% and of good quality when >80%. Results: The search yielded 343 citations of which 7 were CPGs and included for the critical appraisal (Table) (one CPG was published in two journals). Five CPGs were published by the gastroenterology associations in Europe (n=2) and Asia (n=3) and two in the United States. The overall median score for the AGREE II domains was 100% for scope and purpose, 72% for stakeholder involvement, 86% for rigor of development, 100% for clarity of presentation, 29% for applicability and 89% for editorial independence. Table presents scores for the AGREE II domains for each included CPG. Conclusion: The findings from our study show that the overall methodological quality of the CPGs for the management of antithrombotic agents in patients undergoing GI endoscopic procedures varies across various domains. Only one CPG included patient representatives in the CPG development process. There is a significant scope for improvement for methodological rigor and the applicability. Table 1. - Clinical practice guidelines included in the critical appraisal using AGREE II instrument. Authors Title Journal AGREE II scores [%] Scope and purpose Stakeholder involvement Rigor of development Clarity of presentation Applicability Editorial independence Overall Acosta et al. The management of antithrombotic agents for patients undergoing GI endoscopy Gastrointest Endosc 2016 Jan;83(1):3-16. doi: 10.1016/j.gie.2015.09.035. 100% 29% 64% 100% 14% 57% 64% Kato et al. Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants Dig Endosc. 2018 Jul;30(4):433-440. doi: 10.1111/den.13184. 100% 57% 64% 86% 29% 79% 61% Chan et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines Gut 2018 Mar;67(3):405-417. doi: 10.1136/gutjnl-2017-315131 100% 86% 79% 100% 14% 100% 73% Farcas et al. Gastrointestinal endoscopy in patients on direct oral anticoagulants. A consensus paper of the Romanian Society of Gastroenterology and Hepatology J Gastrointestin Liver Dis. 2018 Jun;27(2):179-187. doi: 10.15403/jgld.2014.1121.272.end. 100% 57% 71% 71% 29% 86% 61% Lim et al. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy Clin Endosc. 2020 Nov;53(6):663-677. doi: 10.5946/ce.2020.192 100% 86% 100% 100% 29% 100% 85% Veitch et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update Endoscopy. 2021 Sep;53(9):947-969. doi: 10.1055/a-1547-2282 100% 100% 100% 100% 43% 100% 90% Abraham et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period 1. J Can Assoc Gastroenterol.2022 5(2):100-101. doi: 10.1093/jcag/gwac010.2. Am J Gastroenterol 2022 117(4):542-558. doi:10.14309/ajg.0000000000001627. 100% 100% 100% 100% 57% 93% 83%

ACG-CAG provided suggestions for periendoscopic management of anticoagulants and antiplatelets.

Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117:542-58. 35297395.

Continuing Medical Education Questions: April 2022.

Article Title: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the peri-endoscopic period.

American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period.

We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.

American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period.

We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1–7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1–7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.

Management of Patients on Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Peri-Endoscopic Period: A Clinical Practice Guideline Dissemination Tool

Barkun, Alan N. MD, MSc (Epi), FACG, CAGF1; Douketis, James MD2; Noseworthy, Peter A. MD3; Laine, Loren MD, FACG4; Telford, Jennifer J. MD, MPH, FACG, CAGF5; Abraham, Neena S. MD, MSc (Epi), FACG6 Author Information

Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists

This study aims to assess current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy. Self-reported data were obtained through a voluntary, anonymous survey of gastroenterologists and gastroenterology trainees in the United States. The survey assessed respondents' approach to, beliefs, and knowledge regarding inpatient periprocedural code status discussions. Four hundred thirty-six gastroenterologists and 83 trainees completed the survey. For patients with an existing do not resuscitate (DNR) order, respondents reversed the code status before endoscopy either all (40.8%, n= 212) or most of the time (18.3%, n= 95). When asked their personal opinion, 32.6% (n=169) supported automatic DNR reversal to full resuscitation attempt during a procedure, 18.5% (n= 96) supported that DNR orders could be sustained, and 48.7% (n= 253) supported offering limited resuscitation. Many gastroenterologists were unaware of institutional (40.7%, n= 211) or national (80.7%, n= 419) policies, and a majority reported that a gastroenterology-specific guideline would be helpful (88.6%, n= 460). Although most of the gastroenterologists reverse DNR orders more than 75% of the time before endoscopy, many also believe patients should be allowed to remain DNR during a procedure and supported a third option for limited resuscitation. Most gastroenterologists were unaware of institutional policies or existing national guidelines. These findings suggest considerable variation in knowledge and current approaches regarding periendoscopic code status reversal.

The effect of somatostatin analogs and acromegaly on the upper gastrointestinal system.

To evaluate the effects of somatostatin analogs and disease activity status on the upper gastrointestinal system in patients with acromegaly. One hundred eighty-one patients with acromegaly were retrospectively assessed. The demographic, biochemical, pathologic, and radiologic data of the patients were evaluated. The upper gastrointestinal endoscopies and endoscopic biopsies were investigated. We divided patients into four groups according to the use of somatostatin analogs, and into two groups according to disease activity. We compared the data of patients between groups A, B, C, and D, and controlled/uncontrolled groups separately. Before and in the peri-endoscopic period, 67 and 27 patients were being treated with octreotide long-acting release (LAR) (group A) and lanreotide autogel (group B), respectively. Twenty-one patients used somatostatin analogs, but they were stopped for various reasons before upper gastrointestinal endoscopy (group C), and 66 patients did not use a somatostatin analog (group D). In the peri-endoscopic period, 103 (60%) patients were responsive to medical and/or surgical treatment and 67 (40%) patients were non-responsive. The rate of gastritis was higher in group A than in groups B and D. The incidence of duodenitis and gastric ulcer was much higher in group D. The rate of gastritis was higher in the controlled group compared to the uncontrolled group. The study showed that octreotide LAR treatment could be a risk factor in addition to known factors for the development of gastritis in patients with acromegaly.

Current evidence and issues of endoscopic submucosal dissection for gastric neoplasms during antithrombotic therapy

Endoscopic submucosal dissection (ESD) for gastric neoplasms is a useful treatment globally. However, postoperative bleeding after gastric ESD is a serious, and sometimes life-threatening complication in patients receiving antithrombotic drugs, because antithrombotic drugs are considered to increase the risk of postoperative bleeding after gastric ESD. In contrast, withdrawal of antithrombotic drugs during the perioperative period increases the risk of thrombotic complications. Guidelines for the management of antithrombotic drugs during the periendoscopic period have been published by different countries, and recent guidelines place greater emphasis on the risk of thromboembolism with the discontinuation of antithrombotic drugs than on the risk of bleeding with the continuation of antithrombotic drugs. Several studies have reported on the validity of these guidelines, and clinical evidence is being established. Most studies reported that gastric ESD under continuation of aspirin or cilostazol did not increase the risk of bleeding, whereas heparin replacement was strongly associated with a higher risk of bleeding. However, the data regarding some clinical issues about the management of antithrombotic drugs, such as the safety of gastric ESD under continuation of thienopyridine, administration of multiple antithrombotic drugs including dual antiplatelet and anticoagulants (warfarin and direct oral anticoagulant), and effective prophylactic methods for postoperative bleeding after gastric ESD are lacking. Larger clinical data are needed to resolve the remaining issues in the future.

Effect of antiplatelet agent number, types, and pre-endoscopic management on post-polypectomy bleeding: validation of endoscopy guidelines.

It remains unclear whether type of antiplatelet (AP) therapy, AP combination therapy, and AP continuing or switching strategy affect the risk of post-polypectomy bleeding (PPB). In this study, we sought to elucidate this risk. We analyzed 1050 patients who underwent colonoscopic polypectomy: 525 AP users and 525 controls matched for age, sex, comorbidities, concomitant non-steroidal anti-inflammatory drugs use, and polyp characteristics who did not receive antithrombotics. PPB risk was evaluated by AP number, type, and continuing or switching strategies during the peri-endoscopic period. In multivariate analysis, bleeding risk increased significantly as the number of AP agents used increased (monotherapy, adjusted odds ratio [aOR], 3.7; dual antiplatelet therapy (DAPT), 4.6; triple antiplatelet therapy (TAPT), 11.1) compared with controls. With monotherapy, significantly increased PPB risk was found for aspirin (aOR 4.3), thienopyridine (aOR 6.3), and cilostazol (aOR 5.9), but not for eicosapentaenoic acid or other APs (beraprost, limaprost, sarpogrelate, dilazep, or dipyridamole). With DAPT, significantly increased PPB risk was found for combination aspirin plus cilostazol, but not aspirin plus other APs. Bleeding rates for continuing monotherapy were 4.3% for aspirin and 0% for thienopyridine, cilostazol, and other APs, respectively. Analysis of this large polypectomy dataset showed that the use of low-dose aspirin, thienopyridine, or cilostazol and a combination of these is associated with increased PPB risk. Although PPB risk was high with DAPT or TAPT, PPB rate in any antiplatelet monotherapy even with a continuing strategy was low at < 5%.

A prospective multicenter observational study evaluating the risk of periendoscopic events in patients using anticoagulants: the Osaka GIANT Study.

Background and study aims An increasing number of patients have been using anticoagulants including anti-vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs); however, in patients using anticoagulants, limited data are available with regard to the risks of gastrointestinal bleeding and thromboembolic events during the peri-endoscopic period. We aimed to evaluate the peri-endoscopic bleeding and thrombotic risks in patients administered VKAs or DOACs. Patients and methods Consecutive patients using anticoagulants who underwent endoscopic biopsy, mucosal resection, or submucosal dissection were prospectively enrolled across 11 hospitals. The primary outcome assessed was difference in incidence of post-procedural gastrointestinal bleeding in patients using VKAs and DOACs. Duration of hospitalization and peri-procedural thromboembolic events were also compared. Results We enrolled 174 patients using VKAs and 37 using DOACs. In total, 16 patients using VKA were excluded from the analysis because of cancellation of endoscopic procedures and contraindications to the use of DOACs; 128 (81 %) patients using VKAs and 17 (46 %) using DOACs received heparin-bridging therapy (HB). The rate of post-procedural gastrointestinal bleeding in DOAC users was similar to that in VKA users (16.2 % vs. 16.4 %, P = 1.000). Duration of hospitalization was significantly longer in patients using VKAs than in those using DOACs (median 15 vs. 7 days, P < 0.0001). Myocardial infarction occurred during pre-endoscopic HB in one patient using VKAs. Conclusion DOAC administration showed similar post-procedural gastrointestinal bleeding risk to VKA administration in patients undergoing endoscopic procedures, but it shortened the hospital stay.

Novel Oral Anticoagulants in the Peri-Endoscopic Period.

Millions of patients in the United States are currently prescribed some form of anticoagulation therapy. Recently, novel oral anticoagulants (NOACs), including direct thrombin inhibitors and direct factor Xa inhibitors, have begun to replace warfarin as the drugs of choice for anticoagulation. As the use of these medications becomes more widespread, it is increasingly important for gastroenterologists to understand the risks associated with performing endoscopic procedures on patients who are taking NOACs. In this review, we provide an overview of the NOACs and current guidelines from international societies regarding the management of patients scheduled to undergo endoscopic procedures who are prescribed these medications. Finally, we offer a perspective on future studies required to adequately investigate and characterize the effects that these drugs have on a patient's risk for bleeding in the peri- and/or postprocedural timeframes.

Sa1031 Management of Antithrombotic Agents in the Peri-Endoscopic Period by Gastroenterologists in a Major Metropolitan Health System

Sa1031 Management of Antithrombotic Agents in the Peri-Endoscopic Period by Gastroenterologists in a Major Metropolitan Health System

Current Practices in the Management of Antithrombotic Therapy During the Periendoscopic Period for Patients With Cardiovascular Disease

The management of antithrombotics during the periendoscopic period is traditionally represented as a doubleedged sword for cardiologists and endoscopists. Appropriate administration prevents thromboembolic events, whereas excessive administration provokes bleeding events. Therefore, cardiologists and endoscopists must consider the risks of bleeding and thromboembolism in individual cases, before deciding whether to continue antithrombotic use. Several guidelines exist concerning antithrombotic management in Asian and Western countries. These guidelines generally classify procedural bleeding risk and thromboembolic risk into high risk and low risk groups and recommend that the two risks be weighed when managing a given patient. Moreover, they generally do not recommend interrupting antithrombotics during the periendoscopic period unless absolutely necessary; however, the details surrounding this point differ among the guidelines after several revisions. In this review, we describe the present state, problems, and future perspectives concerning the management of antithrombotics in patients with cardiovascular disease undergoing gastrointestinal endoscopy.

Blood thinners and gastrointestinal endoscopy.

As the number of diagnostic and therapeutic gastrointestinal endoscopies is increasing, and there is an increase in number of patients taking blood thinners, we are seeing more and more patients on blood thinners prior to endoscopic procedures. Gastrointestinal bleeding or thromboembolism can occur in this category of patients in the periendoscopic period. To better manage these patients, endoscopists should have a clear concept about the various blood thinners in the market. Patients' risk of thromboembolism off anticoagulation, and the risk of bleeding from endoscopic procedures should be assessed prior to endoscopy. The endoscopic procedure should be done when it is safe to do it.