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      Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

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          Abstract

          The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy.

          P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor)

          For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).

          Warfarin

          The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.

          Direct Oral Anticoagulants (DOAC)

          For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30–50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

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          Most cited references168

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          Complications of endoscopic biliary sphincterotomy.

          Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
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            Endoscopic sphincterotomy complications and their management: an attempt at consensus.

            Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.
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              Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.

              It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding.
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                Author and article information

                Journal
                Gut
                Gut
                gutjnl
                gut
                Gut
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0017-5749
                1468-3288
                March 2016
                : 65
                : 3
                : 374-389
                Affiliations
                [1 ]Department of Gastroenterology, New Cross Hospital , Wolverhampton, UK
                [2 ]Department of Gastroenterology, Hôpital Universitaire L'Archet 2 , Nice Cedex 3, France
                [3 ]Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital , Leicester, UK
                [4 ]Service Unité Endoscopie Digestive, Hopital Saint Joseph , Marseille, France
                [5 ]Department of Haematology, Addenbrookes Hospital , Cambridge, UK
                [6 ]Department of Gastroenterology, Auckland City Hospital , Auckland, New Zealand
                [7 ]Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce , Como, Italy
                [8 ]AntiCoagulation Europe , Bromley, Kent, UK
                [9 ]Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center , Afula, Israel
                [10 ]Rappaport Faculty of Medicine Technion, Israel Institute of Technology , Israel
                [11 ]Digestive Endoscopy Unit, Catholic University , Rome, Italy
                [12 ]Gedyt Endoscopy Center , Buenos Aires, Argentina
                Author notes
                [Correspondence to ] Dr Andrew Veitch, Department of Gastroenterology, New Cross Hospital, Wolverhampton WV10 0QP, UK; andrew.veitch@ 123456nhs.net

                This article is published simultaneously in the journal Endoscopy. Copyright 2016 © Georg Thieme Verlag KG

                Article
                gutjnl-2015-311110
                10.1136/gutjnl-2015-311110
                4789831
                26873868
                4784e835-76d6-4341-a823-c534af643bc9
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 16 November 2015
                : 30 December 2015
                : 4 January 2016
                Categories
                1506
                Guidelines
                Custom metadata
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                Gastroenterology & Hepatology
                endoscopy
                Gastroenterology & Hepatology
                endoscopy

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