Post written by Saurabh Chandan, MD, from Creighton University School of Medicine, Omaha, Nebraska, USA.

The main focus of our study was to assess the outcomes of ERCP with sphincterotomy among patients on anticoagulant (AC) and antiplatelet (APT) agents. We performed a retrospective analysis using the TriNetX database, which is a global, federated research network providing real-time access to de-identified electronic health records of more than 85 million patients within 53 healthcare organizations in the United States.

Society guidelines state that although continued use of aspirin is generally recommended for patients requiring ERCP with sphincterotomy, APT agents such as clopidogrel, prasugrel, and ticagrelor should be stopped 5 days prior to the procedure.

In addition, AC agents including warfarin are recommended to be stopped 5 days prior, whereas the last dose of others such as dabigatran, rivaroxaban, and apixaban should be >48 hours before the procedure. These recommendations are based on underpowered observational cohort studies.

Data regarding dual APT (DAPT) use and risk of post-sphincterotomy bleeding also are conflicting. A recent analysis of 164 patients concluded that post-ERCP bleeding rates were not significantly higher in patients receiving DAPT than in patients taking aspirin alone. Another pooled analysis of 6 studies showed that even APT monotherapy was associated with a modestly increased risk of post-sphincterotomy bleeding. 

The aim of our study was to evaluate the risk and outcomes of post-sphincterotomy bleeding in the AC cohort, including among those patients receiving heparin bridging therapy, as well as the APT cohort compared with the control cohort.

Our analysis found that patients receiving AC and APT therapy are indeed at a higher risk of post-sphincterotomy bleeding after ERCP compared with matched control subjects. In addition, although concurrent use of aspirin with AC agents further increased this risk compared with taking AC agents alone, the same was not observed in patients taking APT agents. In these patients, DAPT did not further increase the risk of bleeding.

Furthermore, although the use of heparin bridging therapy did not increase the risk of post-sphincterotomy bleeding, resumption of AC therapy within 24 hours of the procedure did. Importantly, patients in both the AC and APT groups were not at a higher risk for need of blood transfusions, intensive care unit care, or all-cause mortality.

Future prospective randomized controlled trials on this topic may be needed to further validate our results.

Graphical Abstract

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