As the majority of gastroenterology procedures are outpatient in nature (i.e., patients are ambulatory), the risk of venous thromboembolism following these procedures is low.
Bleeding after high risk procedures may be increased in frequency, but is rarely associated with any significant morbidity or mortality.
High risk procedures:
- Biliary or pancreatic Sphincterotomy
- Pneumatic or bougie dilation
- PEG placement
- Therapeutic Balloon assisted enteroscopy
- EUS with FNA
- Endoscopic Hemostasis
- Tumor ablation by anty technique
- Treatment of varices
- Large polypectomy
Low risk procedures:
- Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including biopsy
- ERCP without sphincterotomy
- EUS without FNA
- Enteroscopy, including diagnostic balloon-assisted enteroscopy
- Capsule endoscopy
- Entral stent deployment( without dilatation)
- Small polypectomy (can be part of any screening colonoscopy). Polyps are found in < 50% of cases. Most endoscopists remove small ones with snare & without electrocautery. Risk of bleeding is felt to be minimal even in patients on anti-thrombotic agents (“polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1cm in size with an acceptable bleeding rate”)
General Recommendations for Pre-Procedure Warfarin Management
- Routine screening colonoscopy /endoscopy (biopsies not planned, but possible): Hold warfarin x3
- Colonoscopy/ endoscopy with planned multiple biopsies: Hold warfarin x5
- Virtual colonoscopy: Hold warfarin x1 (day of prep only)
Management of Anticoagulants & Antiplatelet Agents Pre and Post Endoscopy, presentation by Thomas Savides, MD
ASGE Standards of Practice Committee. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1061-1070.
Friedland S, Sedehi D, Soetikno R. Colonoscopic polypectomy in anticoagulated patients. World J Gastroenterol. 2009 Apr 28;15(16):1973-6.
Friedland S, Soetikno R. Colonoscopy with polypectomy in anticoagulated patients. Gastrointest Endosc. 2006 Jul;64(1):98-100.
Special thanks to
Syed Fehmi, MD and
Thomas Savides, MD for their expert guidance.