What are the risks of Endoscopic Retrograde Cholangiopancreatography (ERCP) in anticoagulated patients?

From the Guidelines

Patients undergoing ERCP while anticoagulated are at an increased risk of bleeding complications, and management should involve temporarily stopping anticoagulation before the procedure, with the goal of minimizing this risk while considering the patient's thrombotic risk. According to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, ERCP with sphincterotomy is considered a high-risk procedure for bleeding. For patients on warfarin, it is recommended to temporarily discontinue the medication and substitute it with low molecular weight heparin (LMWH) before the procedure, with a check of the INR to ensure it is below 1.5 1. For patients on direct oral anticoagulants (DOACs), the last dose should be taken at least 48 hours before the procedure, with adjustments for renal function, such as taking the last dose 72 hours prior for patients on dabigatran with a creatinine clearance (CrCl) of 30-50 mL/min 1. Key considerations include:

• The risk of bleeding associated with ERCP in anticoagulated patients
• The need for careful management of anticoagulation before, during, and after the procedure
• The importance of balancing the risks of bleeding and thrombosis in the perioperative period
• The role of bridging therapy with low molecular weight heparin for patients at high thrombotic risk. In clinical practice, the decision to anticoagulate or not should be made on a case-by-case basis, taking into account the individual patient's risk factors for bleeding and thrombosis, as well as the specific details of the ERCP procedure being performed, as outlined in the guidelines 1.

From the Research

ERCP in Anticoagulated Patients

• ERCP (Endoscopic Retrograde Cholangiopancreatography) is a procedure that can be challenging in anticoagulated patients due to the risk of bleeding complications 2, 3, 4.
• The management of bleeding complications in anticoagulated patients requires a multidisciplinary approach, including the use of specific antidotes, supportive care, and nonspecific support for hemostasis 2, 4.
• The treatment of patients presenting to the hospital with major bleeding includes the replacement of blood components, reversing the anticoagulated state, and the use of specific agents such as idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors 4.

Bleeding Risks and Management

• The risk of bleeding complications is higher in patients with renal insufficiency, and the use of novel oral anticoagulants (NOACs) may be associated with a lower risk of major or clinically relevant nonmajor bleeding compared to conventional anticoagulants 5.
• The management of bleeding complications in patients on anticoagulant therapy requires adequate reversal of the anticoagulant effect, which can be achieved with specific antidotes or supportive care 2, 3, 4.
• The use of enoxaparin as an alternative method of anticoagulation may be useful in patients who require chronic anticoagulation and a procedure, avoiding hospitalization and the need for frequent monitoring 6.

Anticoagulant Reversal

• The reversal of anticoagulation is crucial in patients with severe bleeding, and specific agents such as idarucizumab and andexanet alfa are available for the reversal of dabigatran and factor Xa inhibitors, respectively 4.
• The use of vitamin K, 4-factor prothrombin complex concentrate, and fresh frozen plasma may also be necessary for the reversal of anticoagulation in patients with severe bleeding 4.
• The resumption of oral anticoagulation after effective treatment of severe bleeding is important to prevent thrombotic complications, and an algorithm for the approach to management of patients with life-threatening oral anticoagulant-associated bleeding is available 4.