Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
Am J Med. 2017 Jul;130(7):786-795. doi: 10.1016/j.amjmed.2017.01.052. Epub 2017 Mar 24.
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
在服用阿司匹林、非甾体抗炎药、抗血小板药物和其他抗凝剂的患者中，经常进行结肠镜检查。这些结肠镜检查通常涉及息肉切除术，可能会出现出血等并发症。如果停止抗凝剂会引发血栓栓塞并发症的风险，必须与继续使用这些药物时发生息肉切除术后出血的风险进行权衡。本文系统地回顾了择期和紧急结肠镜检查期间抗凝管理。对于接受结肠镜息肉切除术的患者，息肉切除术后出血的总体风险<0.5%。息肉切除术后出血的危险因素包括大息肉大小和抗凝剂的使用，特别是华法林和噻吩吡啶类药物。对于在结肠镜检查前不停止使用阿司匹林或其他非甾体抗炎药的患者，与未服用这些药物的患者相比，息肉切除术后出血的发生率没有显著差异。对于继续使用噻吩吡啶类药物并进行息肉切除术的患者，延迟性息肉切除术后出血的风险约为 2.4%。即使对于中断华法林的患者，息肉切除术后出血的风险也会增加。直接口服抗凝剂（直接凝血酶抑制剂和因子 Xa 抑制剂）起效迅速，停药迅速，围手术期一般不需要桥接。对于噻吩吡啶类药物、华法林和直接口服抗凝剂，中断或继续使用这些药物进行内镜检查将需要大量的临床判断。
