Should low‑dose aspirin (81 mg daily) be continued for a patient undergoing endoscopic retrograde cholangiopancreatography (ERCP), and does it need to be stopped if a sphincterotomy is planned?

Aspirin During ERCP

Continue aspirin during ERCP with sphincterotomy—do not stop it. This is the clear recommendation from the most recent 2021 BSG/ESGE guidelines, which state that aspirin should be continued for all endoscopic procedures, including high-risk procedures like ERCP with sphincterotomy 1.

Key Recommendation

The 2021 BSG/ESGE guidelines explicitly classify ERCP with sphincterotomy as a HIGH-RISK procedure but make a strong recommendation (with low quality evidence) to continue aspirin regardless of procedure risk 1. The only exception mentioned in these guidelines is ampullectomy, which is not relevant to standard ERCP with sphincterotomy 1.

Risk Stratification Context

For patients on aspirin monotherapy:

• Continue aspirin through the procedure
• No interruption needed regardless of whether sphincterotomy is planned
• This applies to both low thrombotic risk and high thrombotic risk patients 1

For patients on dual antiplatelet therapy (DAPT):

• Continue aspirin
• Stop the P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) 7 days before the procedure if the patient has LOW thrombotic risk
• For HIGH thrombotic risk patients (recent stent, recent ACS), consult cardiology but still continue aspirin 1

Evidence Nuances and Contradictions

There is some conflicting research evidence that warrants discussion:

Supporting continuation:

• A 2013 case-control study of 308 patients found no increased risk of post-sphincterotomy bleeding with aspirin (14.9% of bleeding cases vs 9.8% of controls were on aspirin, p>0.05) 2
• A 2022 meta-analysis showed no significant difference in bleeding between DAPT and aspirin alone (OR 1.14,95% CI 0.46-2.81) 3

Suggesting increased risk:

• A 2022 systematic review found aspirin monotherapy modestly increased post-sphincterotomy bleeding (OR 1.53,95% CI 1.03-2.28), though the number needed to harm was 185 patients 4
• A 2002 retrospective study showed aspirin increased bleeding risk (9.7% vs 3.9%, p=0.01), and importantly, stopping aspirin for 1 week did NOT reduce this risk (9.5% bleeding rate when stopped vs 9.7% when continued, p=0.96) 5

Clinical Algorithm

Step 1: Identify the patient's thrombotic risk

• High risk: Recent coronary stent (<6-12 months), recent ACS, cerebrovascular disease, peripheral vascular disease
• Low risk: No recent cardiac events, aspirin for primary prevention or stable secondary prevention

Step 2: Manage aspirin

• Continue aspirin in ALL cases 1
• Counsel patient about slightly increased bleeding risk (though absolute risk remains low)

Step 3: If on DAPT, manage the second agent

• Low thrombotic risk: Stop P2Y12 inhibitor 7 days before, restart 1-2 days after procedure
• High thrombotic risk: Consult interventional cardiology, but generally continue aspirin and consider continuing DAPT if within 6 months of stent placement 1, 6

Step 4: Post-procedure

• Resume any held antiplatelet agents 1-3 days after procedure depending on hemostasis 1
• Monitor for delayed bleeding (counsel patient this risk is slightly elevated on antiplatelets)

Critical Pitfalls to Avoid

1. Do not stop aspirin "to be safe"—the 2002 study definitively showed stopping aspirin 1 week before sphincterotomy did NOT reduce bleeding risk 5. The thrombotic risk of stopping aspirin (stroke, MI, stent thrombosis) far outweighs the modest bleeding risk.

2. Do not confuse ERCP with stenting vs ERCP with sphincterotomy—the guidelines classify diagnostic ERCP and ERCP with stenting as LOW-RISK procedures, but ERCP with sphincterotomy is HIGH-RISK 1. However, aspirin is continued for both.

3. Do not apply older 2018 APAGE/APSDE guidelines—these suggested discontinuing antiplatelets for high-risk procedures 6, but the more recent 2021 BSG/ESGE guidelines supersede this with stronger evidence supporting aspirin continuation 1.

4. For patients on aspirin for secondary prevention (prior MI, stroke, stent), the risk of stopping aspirin is particularly dangerous—these patients should NEVER have aspirin stopped for ERCP 1.

Quality of Evidence Consideration

The guideline recommendation to continue aspirin is a strong recommendation but based on low quality evidence 1. This reflects the reality that most studies are observational with small sample sizes. However, the consistency of the recommendation across multiple guidelines, combined with evidence that stopping aspirin doesn't reduce bleeding risk 5, supports the decision to continue therapy. The thrombotic consequences of stopping aspirin (MI, stroke, death) are far more severe than the manageable risk of post-sphincterotomy bleeding, which can typically be controlled endoscopically.