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 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.

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], when the snare is pulled through the polyp without the use of cautery ("cheese wiring") in patients with coagulation disorders (although bleeding is not a problem with small polyps removed in this manner [14]), and it is more likely with large polyps, those 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. They also found that pedunculated polyps and sessile polyps over 1 cm in diameter are more likely to bleed immediately after removal. This is similar to our experience, where the risk of significant bleeding is greatest with sessile polyps larger than 2.5 cm in diameter, followed by those with a thick stalk; significant bleeding is least likely to occur if a polyp is mistakenly pulled off with a snare, since this only happens with relatively small polyps.

Polyps less than 1 cm in diameter have been safely removed in patients on warfarin therapy who have 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.

Most bleeding that occurs immediately after resection can be controlled by the endoscopist [2]. The technique for controlling bleeding depends upon the severity of bleeding, the type of polyp, and individual preference. A combination of techniques is frequently required (see below). Patients whose polypectomies were performed on an ambulatory basis may be sent home after hemostasis has been achieved, assuming that the bleeding was not torrential, and the patient was stable throughout the bleeding episode. We have not had any patient return with further bleeding within 24 hours following treatment of immediate postpolypectomy bleeding.