Does aspirin (acetylsalicylic acid) need to be discontinued prior to Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Aspirin Management for ERCP

No, aspirin does not need to be discontinued prior to ERCP—it should be continued regardless of whether sphincterotomy is planned. 1

Risk Classification of ERCP

ERCP with sphincterotomy is classified as a low-risk procedure for bleeding according to current BSG/ESGE guidelines, despite being historically considered high-risk. 1 This reclassification is critical because it fundamentally changes antiplatelet management—aspirin continuation is now the standard of care for all low-risk procedures. 1

Evidence-Based Recommendations

For All Patients on Aspirin Monotherapy

• Continue aspirin through the procedure without interruption, regardless of whether diagnostic ERCP, sphincterotomy, or biliary/pancreatic stenting is planned. 1
• The strong recommendation to continue aspirin applies to all endoscopic procedures with the sole exception of ampullectomy (where evidence is weaker). 1
• This recommendation carries a strong recommendation with low quality evidence designation, but the thrombotic risks of discontinuation outweigh bleeding risks. 1

For Patients on Dual Antiplatelet Therapy (DAPT)

The management depends on thrombotic risk stratification:

High Thrombotic Risk Patients (recent stent, recent ACS, or within 6 months of PCI):

• Continue aspirin throughout the procedure. 1
• Liaise with interventional cardiology before considering discontinuation of P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor). 1
• If P2Y12 inhibitor must be stopped, discontinue 7 days before the procedure but maintain aspirin. 1
• Resume P2Y12 inhibitor 1-2 days post-procedure. 1

Low Thrombotic Risk Patients (>6 months post-stent or stable CAD):

• Continue aspirin throughout. 1
• P2Y12 inhibitors may be discontinued 7 days before if deemed necessary, but aspirin must continue. 1

Clinical Context and Nuances

Bleeding Risk Reality

While antiplatelet monotherapy does modestly increase post-sphincterotomy bleeding risk (OR 1.53,95% CI 1.03-2.28), the absolute risk increase is small with a number needed to harm of 185 patients. 2 Importantly, meta-analysis shows no significant difference in bleeding rates between DAPT and aspirin alone (OR 1.14,95% CI 0.46-2.81), suggesting bleeding is more procedure-related than medication-related. 3

Thrombotic Risk of Discontinuation

The cardiovascular risks of aspirin discontinuation are substantial and well-documented:

• Thrombotic events cluster early after aspirin discontinuation, particularly in patients with coronary stents. 4
• The risk increases exponentially after percutaneous coronary intervention, especially with drug-eluting stents. 4
• For patients with CAD, the cardiac event risk from discontinuation outweighs procedural bleeding risk. 5

Critical Pitfalls to Avoid

• Never discontinue aspirin reflexively based on outdated protocols that classified ERCP as high-risk—current guidelines explicitly reclassify it as low-risk. 1
• Do not stop aspirin without cardiology consultation in patients with recent stents (<6 months for drug-eluting stents, <1 month for bare metal stents). 5
• Avoid prolonged aspirin discontinuation if it must be stopped for ampullectomy—resume as soon as hemostasis is achieved. 1
• Counsel patients about the small increased bleeding risk (which exists even with aspirin continuation) versus the substantial thrombotic risk of discontinuation. 1

Post-Procedure Management

• If any antiplatelet was discontinued, resume 1-2 days after the procedure depending on hemostatic adequacy. 1
• Patients should be informed of increased post-procedure hemorrhage risk compared to those not on antiplatelets. 1
• For acute GI hemorrhage occurring in patients on aspirin for secondary prevention, aspirin should be recommenced as soon as hemostasis is achieved. 1