Veitch Andrew M
New Cross Hospital, Wolverhampton, WV10 0QP, UK.
Curr Treat Options Gastroenterol. 2017 Jun;15(2):256-267. doi: 10.1007/s11938-017-0137-z.
Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
接受内镜检查的抗凝或抗血小板治疗患者的管理，需要在因检查导致的出血风险与因中断抗血栓治疗导致的血栓形成风险之间取得平衡。出血通常可通过内镜控制，但血栓形成有时可能导致心肌梗死或中风，造成永久性残疾或死亡。对于择期手术，有足够的时间来规划抗血栓治疗的最佳管理方案。国际指南已经发布，但建议基于有限的证据并经适当医学专家会诊得出，而且患者情况很重要。接受冠状动脉支架双重抗血小板治疗的患者，如果治疗中断，血栓形成风险特别高。直接口服抗凝剂在抗凝管理方面是一项重大进展，但可能会增加自发性胃肠道出血的风险，并且在内镜治疗后出血时管理起来较为困难。对于择期内镜检查，可能有合适的替代检查方法，而且如果高风险抗血栓治疗是暂时的，一些患者可以推迟治疗。抗血栓治疗期间的胃肠道出血可能因潜在的血栓形成以及出血而危及生命。直接口服抗凝剂（DOACs）的管理尤其具有挑战性，但达比加群有逆转剂可用，其他逆转剂也在研发中。治疗性操作或出血后重新开始抗血栓治疗的最安全时间研究较少，文中讨论了相关风险因素并给出了管理建议。尽管已经制定了指南，但在内镜检查抗血栓治疗的管理方面，尤其是对于新型药物，仍存在很多不确定性，需要进一步研究。
