Gastrointestinal Endoscopic Interventions During Antithrombotic Therapy: A Comprehensive Review of Bleeding Risk and Periprocedural Management

The increasing use of antiplatelet and anticoagulant therapy has made periprocedural management a central issue in patients undergoing diagnostic and therapeutic endoscopy. Upper endoscopy and colonoscopy are commonly performed in patients receiving aspirin, P2Y12 receptor inhibitors, warfarin, or direct oral anticoagulants, and the clinical decision to continue, interrupt, or bridge therapy requires balancing procedure-related bleeding against thromboembolic risk. Diagnostic esophagogastroduodenoscopy and colonoscopy with mucosal biopsy are generally low-risk procedures and can usually be performed without interruption of most antithrombotic agents. In contrast, colonoscopic polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and other advanced therapeutic interventions carry a higher delayed bleeding risk, particularly in patients receiving anticoagulants or multiple antithrombotic drugs. Current society guidelines generally support continuation of aspirin, temporary interruption of P2Y12 receptor inhibitors for elective high-risk procedures when thrombotic risk permits, brief interruption of direct oral anticoagulants for high-risk interventions, and avoidance of routine heparin bridging except in selected patients with very high thromboembolic risk. Evidence from randomized trials, cohort studies, and meta-analyses supports cold snare polypectomy as a bleeding-sparing technique for small colorectal polyps, especially in anticoagulated patients.