Aspirin Management for Colonoscopy
Aspirin should NOT be held before colonoscopy—continue it through the procedure regardless of whether polypectomy is anticipated. 1, 2
Key Recommendation by Procedure Risk
For Diagnostic Colonoscopy (Low-Risk Procedure)
- Continue aspirin without interruption 1, 2
- Diagnostic colonoscopy with biopsy is classified as low-risk, and aspirin continuation is safe 1, 2
For Colonoscopy with Polypectomy (High-Risk Procedure)
- Continue aspirin even when polypectomy is planned 1
- This applies to both patients at low and high thrombotic risk 1
- Multiple studies demonstrate aspirin monotherapy is safe during colonoscopic polypectomy 1, 3
For Advanced Resection Procedures (EMR/ESD)
- Continue aspirin through endoscopic mucosal resection (EMR) 1
- Continue aspirin through endoscopic submucosal dissection (ESD) 1
- Retrospective studies and meta-analyses confirm no significant increase in delayed bleeding with continued aspirin during ESD 1
- Inappropriate discontinuation of aspirin significantly increases thrombotic risk 1
Critical Distinction: Aspirin vs. Other Antiplatelet Agents
This recommendation applies ONLY to aspirin—not to P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor):
- P2Y12 inhibitors should be stopped 7 days before high-risk procedures in patients at low thrombotic risk 1
- For patients on dual antiplatelet therapy (DAPT), continue aspirin but hold the P2Y12 inhibitor 1
- For high thrombotic risk patients (recent coronary stent, acute coronary syndrome), consult interventional cardiology before stopping any antiplatelet agent 1
Evidence Quality and Rationale
The 2021 BSG/ESGE guidelines provide the strongest evidence base 1:
- Strong recommendation with moderate-to-high quality evidence for continuing aspirin 1
- Research demonstrates aspirin monotherapy does not significantly increase post-polypectomy bleeding risk 1, 3
- A large Veterans Affairs study of 1,174 patients found no difference in bleeding rates between aspirin users (3.2%) versus non-users (3.0%) 3
Thrombotic Risk Considerations
The risk-benefit calculation strongly favors continuing aspirin:
- Aspirin interruption increases cardiovascular/cerebrovascular events three-fold 1
- 70% of thrombotic events occur within 7-10 days of aspirin discontinuation 1
- Post-polypectomy bleeding is manageable endoscopically and rarely fatal, whereas thrombotic stroke causes permanent disability and cardiac events can be fatal 1
Common Pitfall to Avoid
Do not confuse aspirin management with clopidogrel management—despite both being antiplatelet agents, they have completely different peri-procedural recommendations 1. Many endoscopy units incorrectly stop aspirin before colonoscopy (32.5% in one U.S. survey), often due to outdated policies or medicolegal concerns rather than evidence-based practice 4.