Management of Antiplatelet Therapy in Patients Undergoing Esophagogastroduodenoscopy (EGD) with Esophageal Dilation

Esophageal dilation is categorized as a high-risk endoscopic procedure according to the 2021 British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines, placing it in the same category as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), percutaneous endoscopic gastrostomy (PEG), therapy of varices, and EUS-guided interventional therapy 1, 2, 3, 4
Diagnostic EGD without dilation is considered low-risk and does not require clopidogrel cessation, according to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1

Management Algorithm Based on Thrombotic Risk

For patients at low thrombotic risk, discontinue clopidogrel 7 days before the procedure (strong recommendation, moderate quality evidence), as recommended by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 2
For patients at low thrombotic risk, continue aspirin throughout the perioperative period, as recommended by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 5
For patients at low thrombotic risk, resume clopidogrel 1-2 days after the procedure depending on hemostatic stability, according to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 3
High thrombotic risk conditions include ischemic heart disease without coronary stent, cerebrovascular disease, peripheral vascular disease, as defined by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 3
For patients at high thrombotic risk, continue aspirin and consult with an interventional cardiologist before making any decision about stopping clopidogrel (strong recommendation, high quality evidence), as recommended by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 3, 4

Resume clopidogrel 1-2 days after the procedure if there are no bleeding complications, according to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 3
Counsel patients that they have an increased risk of post-procedure hemorrhage compared to patients not on antiplatelet therapy, as stated by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 4

Do not bridge with heparin when stopping clopidogrel, as recommended by the European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1
Do not stop aspirin in patients on DAPT who require clopidogrel cessation, as aspirin should be continued throughout the perioperative period, according to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, 5