Endoskopische Prozeduren bei Patienten unter antithrombotischer Medikation – Risiken und praktisches Vorgehen

Zusammenfassung

In die Entscheidung, wie mit einer antithrombotischen Therapie umzugehen ist, wenn eine endoskopische Intervention im Bereich des Gastrointestinaltrakts ansteht, geht sowohl das Blutungsrisiko der Maßnahme als auch das Risiko thrombembolischer Komplikationen bei Pausieren der Medikation ein. Das Blutungsrisiko endoskopischer Maßnahmen ohne absehbare Eröffnung der Blutbahn und bei endoskopischen Biopsien ist vernachlässigbar, auch bei oraler Antikoagulation. Diese muss daher nur pausiert werden, wenn blutungsgefährdete Interventionen wie Polypektomie, EPT o. Ä. anstehen. Bei hohem Risiko für thrombembolische Komplikationen wie Kunstklappe in Mitralposition oder Vorhofflimmern mit Risikofaktoren muss passager auf kürzer wirksame und damit besser steuerbare Antikoagulanzien gewechselt werden („Bridging”). Bei Therapie mit Plättchenfunktionshemmern und niedrigem Blutungsrisiko inkl. Biopsie bestehen keine Bedenken gegen den Eingriff. Vor unaufschiebbaren Eingriffen mit hohem Blutungsrisiko soll Clopidogrel nach Rücksprache mit dem Kardiologen für eine Woche pausiert werden. Für die Koloskopie z. B. in Form der Screening-Koloskopie bestehen 2 Optionen: 1. Pausieren einer oralen Antikoagulation (ggf. mit Bridging) bzw. Clopidogrelmedikation zur Koloskopie, 2. Weiterführen der antithrombotischen Medikation mit erneuter elektiver Endoskopie zur Polypektomie bei reduzierter antithrombotischer Medikation, wenn Polypen, die nicht durch Biopsie entfernt werden konnten, entdeckt wurden. Die Entscheidung zwischen diesen Optionen muss individuell fallen.

Abstract

The decision how to handle an antithrombotic treatment when an intervention during GI endoscopy is planned is influenced both by the risk of bleeding and by the thomboembolic risk when treatment is suspended. The risk of bleeding is negligible even when on oral anticoagulants in diagnostic procedures with standard forceps biopsies. Oral anticoagulation has to be stopped, however, when planning invasive procedures such as polypectomy or EPT. In the case of patients with a high risk of thromboembolic complications such as artificial valves in mitral position or atrial fibrillation with risk factors, one has to temporarily switch to anticoagulants with shorter action (”bridging”). Treatment with inhibitors of platelet function does not preclude procedures with a low risk of bleeding including forceps biopsy. Urgent procedures with a high risk of bleeding should be performed after stopping clopidogrel one week previously but only after consultation with the treating cardiologist. In the case of colonoscopy, in particular as a screening procedure, there are two options: 1) stopping oral anticoagulation (with or without bridging) or clopidogrel, respectively, or 2) continuing antithrombotic treatment and performing a second elective endoscopy for polypectomy with tapered antithrombotic medication if polyps are found which are not amenable to resection by biopsy forceps. The choice between these two options has to be made individually.

Schlüsselwörter

gastrointestinale Blutung - Endoskopie - Blutgerinnung

Key words

gastrointestinal bleeding - endoscopy - coagulation

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