Endoscopic sphincterotomy (EST), especially when anticoagulants are used, carries a significant risk of delayed bleeding. However, the relationship between the use of antithrombotic agents, including direct oral anticoagulants, and post-EST bleeding remains unclear. This study aimed to identify the risk factors for post-EST delayed bleeding when antithrombotic agents were administered according to the guidelines.

We analyzed cases of patients who underwent endoscopic retrograde cholangiopancreatography and EST between January 2018 and August 2022, focusing on those with normal anatomy and naïve papillae. We examined the incidence of post-EST bleeding, endoscopic retrograde cholangiopancreatography procedure details, severity and timing of post-EST delayed bleeding, hemostatic interventions, and factors related to post-EST delayed bleeding.

Among the 502 patients included, 76 (15%) were taking antithrombotic agents. Post-endoscopic retrograde cholangiopancreatography delayed bleeding was noted in seven patients (1.4%). Mild, moderate, and severe delayed bleeding occurred in four, one, and two cases, respectively. Hemostatic injection completely controlled cases of delayed bleeding. Multivariate analysis identified a 1-day direct oral anticoagulants interruption (odds ratio: 20.5, 95% confidence interval: 3.33-125, p = 0.0011) and dialysis (odds ratio: 38.7, 95% confidence interval: 2.4-624, p = 0.0099) as significant risk factors for delayed bleeding. No thromboembolic events related to the discontinuation of antithrombotic drugs were observed.

A 1-day direct oral anticoagulants interruption and dialysis are independent risk factors for post-EST delayed bleeding, necessitating careful consideration.

Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.

An increasing number of patients with antithrombotic therapies are undergoing endoscopic retrograde cholangiopancreatography (ERCP). Interruption of antithrombotic therapies may be associated with a higher risk of symptomatic thromboembolic (TE) events. We aimed to investigate the risk of symptomatic TE events among patients undergoing ERCP.

A retrospective cohort study on patients at risk for symptomatic TE events who had undergone ERCP from January 2016 to October 2023 was conducted. A total of 2,482 patients who had undergone ERCP were included in this study. We compared the risk of symptomatic TE events within 30 days after ERCP between the group treated with antithrombotic agent and the group not treated with antithrombotic agent using multivariate regression analysis adjusted for covariates.

A total of 15 patients (0.60%, 15/2,482) developed symptomatic TE events within 30 days after ERCP. The symptomatic TE event rate in subjects on any antithrombotic drug was 1.46% with an odds ratio (OR) of 5.267 (n = 689, 95% CI 1.79-15.46, p = 0.002), compared with those not treated with antithrombotic drugs (n = 1,793). The symptomatic TE event rate in subjects on temporary interruption of antithrombotic drugs was 1.48% with an OR of 5.36 (n = 677, 95% CI 1.83-15.74, p = 0.002), compared with those not treated with antithrombotic drugs (n = 1,793). Multivariate regression analysis indicated that patients with high-risk conditions had a significantly higher risk of post-ERCP symptomatic TE events (adjusted OR 11.73, 95% CI 2.23-61.70).

Interruption of antithrombotic drugs is associated with higher post-ERCP symptomatic TE events, particularly in high-risk conditions.

Although post-procedural bleedings are infrequent in patients with cirrhosis, they are associated with significant morbidity and mortality. Therefore, predicting and preventing such bleedings is important. Established predictors of post-procedural bleeding include high-bleeding risk procedure, severe cirrhosis and high body mass index; prognostic value of anemia, acute kidney injury and bacterial infection is more uncertain. While prothrombin time and international normalized ratio do not predict post-procedural bleeding, some evidence suggests that platelet count, whole blood thrombin generation assay and viscoelastic tests may be helpful in this context. Prevention of postprocedural bleeding involves careful management of antithrombotic drugs during the periprocedural period. Patients with cirrhosis present unique challenges due to altered pharmacokinetics and pharmacodynamics of antithrombotic drugs, but there is a lack of dedicated studies specifically focused on this patient population. Guidelines for periprocedural management of antithrombotic drugs developed for patients without liver disease are thus applied to those with cirrhosis. Some technical aspects may decrease the risk of post-procedural bleeding, namely ultrasoundguidance, opting for transjugular route rather than percutaneous route, and the level of expertise of the operator. The effectiveness of platelet transfusions or thrombopoietin-receptor agonists remains uncertain. Transfusion of fresh-frozen plasma, of fibrinogen, and administration of tranexamic acid are not recommended for reducing post-procedural bleeding in patients with cirrhosis. In conclusion, prediction of post-procedural requires a global approach taking into account the patients characteristics, the risk of the procedure, and the platelet count. There is little data to support prophylactic correction of hemostasis, and dedicated studies are needed.

Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Antithrombotic agents, including antiplatelet agent and anticoagulants are widely used in Korea due to increasing incidence of cardio-cerebrovascular disease and aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. Clinical practice guideline regarding this issue which was developed by the Korean Society of Gastrointestinal Endoscopy was published in 2020. However, since then, new evidence has emerged for the use of dual antiplatelet therapy and direct anticoagulant management, and revised guidelines were issued in the US and Europe. Accordingly, the previous guidelines were revised, cardiologists also participated in the development group, and the recommendations went through a consensus process among international experts. This guideline presents 14 recommendations made according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and was reviewed by multidisciplinary experts. This guideline provides useful information that can assist endoscopists in the management of patients on antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

GI bleeding after ERCP is a serious adverse event and most commonly occurs after endoscopic biliary and/or pancreatic sphincterotomy. Although the strength of available evidence for post-sphincterotomy GI bleeding risk is high for therapeutic warfarin and heparin, it remains unknown for antiplatelet agents like clopidogrel and prasugrel. We conducted a retrospective United States-based, propensity-matched cohort study to assess the risk of post-sphincterotomy bleeding in patients receiving anticoagulant (AC) and antiplatelet (APT) therapy.

We analyzed the U.S. Collaborative Network in the TriNetX platform through December 27, 2022, to include patients receiving APT and AC therapy who underwent ERCP within 7 days of hospitalization. One-to-one propensity score matching was performed. The primary outcome was the incidence of GI bleeding within 7 days of sphincterotomy. Secondary outcomes included need for blood transfusion, intensive care unit care, and all-cause mortality within 30 days of bleeding.

Overall, 2806 patients (1806 in the AC cohort and 1000 in the APT cohort) underwent ERCP with sphincterotomy. One-to-one propensity score matching was performed for age, body mass index ≥30 kg/m2, gender, race, ethnicity, diabetes mellitus, nicotine dependence, presence and severity of chronic kidney disease, cirrhosis, and thrombocytopenia between the cohorts. Patients in both cohorts had an increased risk of post-sphincterotomy bleeding compared with matched control subjects (adjusted odds ratios of 3.6 [95% confidence interval, 2.58-5.06] and 2.2 [95% confidence interval, 1.43-3.56], respectively). Although heparin bridging therapy and concurrent use of aspirin did not further increase the risk of GI bleeding, resumption of AC within 24 hours' postprocedure did. Neither cohort of patients was at an increased risk for blood transfusion, intensive care unit care, or all-cause mortality.

Our database analysis shows that patients receiving AC and APT therapy are at a higher risk of post-sphincterotomy bleeding compared with matched control subjects. An appropriate drug cessation period or alternative biliary decompression modalities may be used in these patients.