Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Bleeding after colonic polypectomy

INTRODUCTION

Postpolypectomy bleeding is the most common complication of colonic polypectomy [1], occurring in 0.3 to 6.1 percent of polypectomies in various reports [2-7]. Bleeding can occur immediately following polypectomy or be delayed from hours to up to 29 days [2,5,6]. The severity of bleeding ranges from arterial pumping to minor oozing. The risk is related to the type and size of the polyp, the location of the polyp, the technique of polypectomy, and the coagulation status of the patient [3-5,8-11]. Bleeding can be controlled endoscopically in the majority of patients. Thus, those who perform polypectomy should also have the ability to perform hemostasis and should have the necessary tools available.

This topic will review bleeding after colonic polypectomy, including measures to decrease the risk of bleeding and the management of bleeding. Other issues related to colonoscopy and polypectomy are discussed separately. (See "Overview of colonoscopy in adults" and "Endoscopic removal of large colon polyps".)

IMMEDIATE BLEEDING

Immediate bleeding has been observed in approximately 1.5 percent of polypectomies [2,12]. The risk is increased when blended current (rather than pure coagulation current) is used [13] and when the snare is pulled through larger polyps without the use of cautery ("cheese wiring") (although bleeding is not a problem with small polyps [ie, less than 1 cm] removed in this manner [14]). Bleeding is also more likely with large polyps (particularly if the patient is anticoagulated), polyps with a thick stalk, and polyps that are sessile [2].

In a multicenter study, immediate bleeding was observed in 2.8 percent of 9336 polypectomies [15]. Independent risk factors for bleeding included age ≥65 years, cardiovascular or chronic renal disease, use of anticoagulants, polyp size greater than 1 cm, polyp morphology, poor bowel preparation, cutting mode of electrosurgical current, and inadvertent cutting of a polyp before current application. This is similar to our experience, where the risk of significant bleeding is greatest with sessile polyps larger than 2 cm in diameter, followed by those with a thick stalk; significant bleeding is unlikely to occur if a small polyp is removed with a snare without cautery.

Polyps up to 1 cm in diameter have been safely removed in patients on warfarin therapy. In some cases, the warfarin has been discontinued warfarin for 36 hours (to avoid a supratherapeutic INR). In a report of 225 polypectomies in 123 anticoagulated patients, three patients bled (one requiring treatment) [16]. All patients in the study had prophylactic endoscopic clips applied to their polypectomy sites. In a randomized trial, 70 patients with a total of 159 polyps up to 1 cm in diameter underwent polypectomy while taking warfarin [17]. Patients were assigned to have their polyps removed either with a cold snare technique or electrocautery. Immediate bleeding occurred in 10 of 70 patients (14 percent) and was more common in patients who had their polyps removed using electrocautery (23 versus 6 percent).

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2014. | This topic last updated: Oct 8, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Rex DK, Lewis BS, Waye JD. Colonoscopy and endoscopic therapy for delayed post-polypectomy hemorrhage. Gastrointest Endosc 1992; 38:127.
  2. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol 1992; 15:347.
  3. Gibbs DH, Opelka FG, Beck DE, et al. Postpolypectomy colonic hemorrhage. Dis Colon Rectum 1996; 39:806.
  4. Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy and flexible sigmoidoscopy. Gastrointest Endosc Clin N Am 1996; 6:343.
  5. Rosen L, Bub DS, Reed JF 3rd, Nastasee SA. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 1993; 36:1126.
  6. Sorbi D, Norton I, Conio M, et al. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51:690.
  7. Levin TR, Zhao W, Conell C, et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006; 145:880.
  8. Singaram C, Torbey CF, Jacoby RF. Delayed postpolypectomy bleeding. Am J Gastroenterol 1995; 90:146.
  9. Nakajima H, Takami H, Yamagata K, et al. Aspirin effects on colonic mucosal bleeding: implications for colonic biopsy and polypectomy. Dis Colon Rectum 1997; 40:1484.
  10. Shiffman ML, Farrel MT, Yee YS. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDS. Gastrointest Endosc 1994; 40:458.
  11. Dyer WS, Quigley EM, Noel SM, et al. Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy. Gastrointest Endosc 1991; 37:361.
  12. Consolo P, Luigiano C, Strangio G, et al. Efficacy, risk factors and complications of endoscopic polypectomy: ten year experience at a single center. World J Gastroenterol 2008; 14:2364.
  13. Van Gossum A, Cozzoli A, Adler M, et al. Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current. Gastrointest Endosc 1992; 38:472.
  14. Tappero G, Gaia E, De Giuli P, et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992; 38:310.
  15. Kim HS, Kim TI, Kim WH, et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 2006; 101:1333.
  16. Friedland S, Sedehi D, Soetikno R. Colonoscopic polypectomy in anticoagulated patients. World J Gastroenterol 2009; 15:1973.
  17. Horiuchi A, Nakayama Y, Kajiyama M, et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014; 79:417.
  18. Conio M, Repici A, Demarquay JF, et al. EMR of large sessile colorectal polyps. Gastrointest Endosc 2004; 60:234.
  19. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342:78.
  20. Sung JY, Chung SC, Low JM, et al. Systemic absorption of epinephrine after endoscopic submucosal injection in patients with bleeding peptic ulcers. Gastrointest Endosc 1993; 39:20.
  21. Binmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993; 25:167.
  22. Parra-Blanco A, Kaminaga N, Kojima T, et al. Hemoclipping for postpolypectomy and postbiopsy colonic bleeding. Gastrointest Endosc 2000; 51:37.
  23. Matsushita M, Hajiro K, Takakuwa H, et al. Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest Endosc 1998; 47:496.
  24. Pfaffenbach B, Adamek RJ, Wegener M. Endoscopic band ligation for treatment of post-polypectomy bleeding. Z Gastroenterol 1996; 34:241.
  25. Slivka A, Parsons WG, Carr-Locke DL. Endoscopic band ligation for treatment of post-polypectomy hemorrhage. Gastrointest Endosc 1994; 40:230.
  26. Witte JT. Band ligation for colonic bleeding: modification of multiband ligating devices for use with a colonoscope. Gastrointest Endosc 2000; 52:762.
  27. Tsuga K, Haruma K, Fujimura J, et al. Evaluation of the colorectal wall in normal subjects and patients with ulcerative colitis using an ultrasonic catheter probe. Gastrointest Endosc 1998; 48:477.
  28. Barker KB, Arnold HL, Fillman EP, et al. Safety of band ligator use in the small bowel and the colon. Gastrointest Endosc 2005; 62:224.
  29. Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 2001; 48:1379.
  30. Dobrowolski S, Dobosz M, Babicki A, et al. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004; 18:990.
  31. Lee SH, Chung IK, Kim SJ, et al. Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy: a prospective randomized, multicenter study. World J Gastroenterol 2007; 13:2973.
  32. Di Giorgio P, De Luca L, Calcagno G, et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy 2004; 36:860.
  33. Paspatis GA, Paraskeva K, Theodoropoulou A, et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 2006; 101:2805; quiz 2913.
  34. Soetikno RM, Friedland S, Lewit V, Woodford S. Lift and ligate: a new technique to treat a bleeding polypectomy stump. Gastrointest Endosc 2000; 52:681.
  35. Zachäus M, Künzel U, Halm U. Bleeding prophylaxis after polypectomy by colonoscopic application of a detachable snare with a mucosectomy cap. Endoscopy 2008; 40 Suppl 2:E159.
  36. Uno Y, Satoh K, Tuji K, et al. Endoscopic ligation by means of clip and detachable snare for management of colonic postpolypectomy hemorrhage. Gastrointest Endosc 1999; 49:113.
  37. Hogan RB, Hogan RB 3rd. Epinephrine volume reduction of giant colon polyps facilitates endoscopic assessment and removal. Gastrointest Endosc 2007; 66:1018.
  38. Iida Y, Miura S, Munemoto Y, et al. Endoscopic resection of large colorectal polyps using a clipping method. Dis Colon Rectum 1994; 37:179.
  39. Katsinelos P, Chatzimavroudis G, Papaziogas B, et al. Endoclipping-assisted resection of large colorectal polyps. Surg Laparosc Endosc Percutan Tech 2008; 18:19.
  40. Watabe H, Yamaji Y, Okamoto M, et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 2006; 64:73.
  41. Buddingh KT, Herngreen T, Haringsma J, et al. Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol 2011; 106:1119.
  42. Sawhney MS, Salfiti N, Nelson DB, et al. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 2008; 40:115.
  43. Choung BS, Kim SH, Ahn DS, et al. Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study. J Clin Gastroenterol 2014; 48:784.
  44. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003; 57:691.
  45. Church JM. Experience in the endoscopic management of large colonic polyps. ANZ J Surg 2003; 73:988.
  46. Zhang Q, An Sl, Chen Zy, et al. Assessment of risk factors for delayed colonic post-polypectomy hemorrhage: a study of 15553 polypectomies from 2005 to 2013. PLoS One 2014; 9:e108290.
  47. Rabeneck L, Paszat LF, Hilsden RJ, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008; 135:1899.
  48. Hui AJ, Wong RM, Ching JY, et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 2004; 59:44.
  49. Witt DM, Delate T, McCool KH, et al. Incidence and predictors of bleeding or thrombosis after polypectomy in patients receiving and not receiving anticoagulation therapy. J Thromb Haemost 2009; 7:1982.
  50. Gandhi S, Narula N, Mosleh W, et al. Meta-analysis: colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy. Aliment Pharmacol Ther 2013; 37:947.
  51. Feagins LA, Iqbal R, Harford WV, et al. Low rate of postpolypectomy bleeding among patients who continue thienopyridine therapy during colonoscopy. Clin Gastroenterol Hepatol 2013; 11:1325.
  52. Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010; 71:998.
  53. Ker TS, Wasserberg N, Beart RW Jr. Colonoscopic perforation and bleeding of the colon can be treated safely without surgery. Am Surg 2004; 70:922.
  54. Carlyle DR, Goldstein HM. Angiographic management of bleeding following transcolonoscopic polypectomy. Am J Dig Dis 1975; 20:1196.
  55. Mezawa S, Homma H, Murase K, et al. Superselective transcatheter embolization for acute lower gastrointestinal hemorrhage after endoscopic mucosal resection: a report of 3 cases. Hepatogastroenterology 2003; 50:735.
  56. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1998; 48:672.
  57. Yousfi M, Gostout CJ, Baron TH, et al. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol 2004; 99:1785.
  58. Feagins LA, Nguyen AD, Iqbal R, Spechler SJ. The prophylactic placement of hemoclips to prevent delayed post-polypectomy bleeding: an unnecessary practice? A case control study. Dig Dis Sci 2014; 59:823.
  59. Lee CK, Lee SH, Park JY, et al. Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding. Gastrointest Endosc 2009; 70:353.