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Management and prevention of bleeding after colonoscopy with polypectomy

Management and prevention of bleeding after colonoscopy with polypectomy
Literature review current through: Jan 2024.
This topic last updated: Apr 25, 2023.

INTRODUCTION — Colonoscopy is one of the most commonly performed endoscopic procedures in clinical practice, and the risk of serious complications, including lower gastrointestinal bleeding, is low [1-3]. Bleeding is usually associated with polypectomy and rarely follows colonoscopy without intervention. Bleeding can occur immediately following polypectomy or can occur in a delayed manner several hours to weeks after the procedure. The severity of bleeding ranges from minor oozing to arterial bleeding, and in most patients, the bleeding can be controlled endoscopically.

This topic will review the management and prevention of bleeding after colonoscopy with polypectomy.

The etiology, clinical features and diagnosis of lower gastrointestinal bleeding are discussed separately. (See "Etiology of lower gastrointestinal bleeding in adults" and "Approach to acute lower gastrointestinal bleeding in adults".)

Other complications related to colonoscopy, including the risk of perforation, are discussed separately. (See "Overview of colonoscopy in adults", section on 'Adverse events'.)

The clinical features, classification and management of colon polyps are discussed separately. (See "Overview of colon polyps", section on 'Endoscopic features and classification'.)

Techniques for removing colon polyps that are ≥2 cm and associated complications are also discussed separately. (See "Endoscopic removal of large colon polyps".)

EPIDEMIOLOGY — Lower gastrointestinal bleeding occurs more frequently in patients who have colonoscopy and polypectomy compared with patients who have a colonoscopy with endoscopic visualization only and no intervention (referred to as a "diagnostic colonoscopy"). In a systematic review of 21 population-based studies of complications related to colonoscopy, the bleeding rate was higher after colonoscopy with polypectomy compared with diagnostic colonoscopy (9.8 versus 0.6 per 1000 colonoscopies) [3].

IMMEDIATE BLEEDING

Definition — Immediate postpolypectomy bleeding (PPB) typically refers to the passage of blood that is not self-limited (eg, bleeding that persists for more than one minute after polypectomy) or that begins before the patient is discharged from the endoscopy unit. However, the definition of immediate PPB varies among studies [4,5].

Incidence and risk factors — Immediate PPB occurs in approximately 1 to 3 percent of all polypectomies [4,6]. Based on the available data and our experience, risk factors for immediate bleeding include polyp size, location and shape (eg, sessile polyps ≥2 cm [particularly if located in the right colon] and pedunculated polyps with a thick stalk), use of anticoagulants, and pure cutting mode of electrosurgical current [7]. Postpolypectomy bleeding is unlikely to occur if a polyp <1 cm is removed with a cold snare technique. (See 'Measures to prevent bleeding' below.)

Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are not associated with an increased risk of immediate PPB, but they have been associated with higher rates of delayed bleeding [5,8]. In a meta-analysis of 11 studies including over 9000 patients, the risk of immediate PPB was not increased in the setting of aspirin or NSAID use. (See 'Delayed bleeding' below.)

Management

Selecting therapy and monitoring — Most bleeding that occurs immediately after polyp resection and continues for greater than one minute can be controlled by the endoscopist [9]. The technique for controlling bleeding depends upon the severity of bleeding, the type of polyp, and endoscopist's preference. In addition, a combination of techniques may be required (eg, injection of diluted epinephrine and endoscopic clip placement). Patients whose polypectomies were performed on an outpatient basis may be sent home after hemostasis has been achieved, provided that the patient remained hemodynamically stable throughout the bleeding episode and during the post procedure observation period.

Bleeding after pedunculated polyp removal — For pedunculated polyps, immediate PPB can usually be stopped by regrasping the pedicle with a snare and holding pressure on the residual stalk to stop blood flow, as the hemostatic cascade occurs. If this is not successful, additional treatment options include endoscopic clip placement, submucosal injection of dilute epinephrine and placement of a nylon loop. Once active bleeding is controlled and hemostasis is achieved, there is usually no further bleeding. (See 'Endoscopic methods' below.)

The technique of holding a snare tightly around a bleeding pedicle for five minutes will usually result in hemostasis. If bleeding recurs upon loosening the snare, reapplying pressure for an additional five minutes will often result in cessation of bleeding. Retransection of the pedicle is not the preferred approach because there may inadequate pedicle tissue remaining to regrasp, in addition to an increased risk of perforation from a deeper resection site.

The regrasping method cannot be used for all sites of immediate PPB following removal of a pedunculated polyp. When pedunculated polyps are resected, even though a long stalk may be transected in its mid portion, the residual stalk may quickly retract and leave a flat polypectomy site. The phenomenon of pedicle disappearance may result in a situation where there is no protuberant stalk remaining on the colon wall to regrasp with a snare.

For patients with remaining stalks in whom bleeding cannot be controlled by using the regrasping maneuver (including those in whom the residual stalk cannot be ensnared), additional measures, such as endoscopic clip placement, submucosal injection of dilute epinephrine and thermal coagulation, are used to achieve hemostasis. These additional methods, which are also used to treat bleeding following removal of a sessile polyp, are discussed below. (See 'Bleeding after sessile polyp removal' below.)

Bleeding after sessile polyp removal — For patients with bleeding following removal of a sessile polyp, initial treatment is usually either by endoscopic clip placement or thermal coagulation. Either of these modalities can be used as monotherapy, or they can be combined with injection therapy with diluted epinephrine. (See 'Bleeding after pedunculated polyp removal' above.)

Epinephrine – Injection therapy is typically used in conjunction with other forms of therapy, such as endoscopic clip placement or thermal coagulation, although injection therapy may also be used as monotherapy for patients with mild oozing. Epinephrine diluted with saline solution to 1:10,000 to 1:20,000 is injected into the submucosa in 0.5 to 2.0 mL aliquots in four quadrants within 3 mm around the bleeding site [10,11]. In patients who are at increased risk of having an adverse event with epinephrine injection, such as those with cardiovascular disease, a dilution of 1:100,000 can be used. The therapeutic effect of the injections is local tamponade at the bleeding site and epinephrine-induced spasm of the bleeding vessel. Endoscopic injection therapy with diluted epinephrine is discussed in more detail separately. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Injection therapy'.)

Endoscopic clips – Endoscopic clip application is performed to achieve hemostasis at the polypectomy site, which occurs in a manner similar to surgical ligation of a feeding blood vessel. Endoscopic clips can be placed directly on the bleeding site to occlude the bleeding vessel, or on the residual stalk [12,13]. For bleeding from a sessile polyp site (ie, flat site), the endoscopic clip is applied directly to the bleeding site first. After control of hemorrhage, endoscopic clips can be placed on either side of the initial clip to occlude the feeding vessel or be used to close the mucosal defect, if it is large or continues to ooze. The average number of clips required to achieve hemostasis in one report was 2.9±2, but the number needed will depend on the type of bleeding and technique used to control the bleeding [13]. The principles of endoscopic clip application are discussed separately. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond".)

Thermal coagulation – Application of thermal coagulation to the bleeding site results in hemostasis, and it is typically performed with a contact probe such as heater probe, bipolar electrocoagulation (BICAP), or the tip of a polypectomy snare. When a heater probe or BICAP is used, the current delivered should be decreased by approximately 50 percent, relative to that used for bleeding ulcers in the upper gastrointestinal tract because the colon wall is very thin and more susceptible to perforation. The heater probe is set at 15 joules and the BICAP at 10 watts and either thermal modality is applied for one to two seconds per application. When the tip of the polypectomy snare is used, the electrosurgical current is set to coagulation mode. (See "Contact thermal devices for the treatment of bleeding peptic ulcers", section on 'Application of thermal coagulation'.)

Multiple applications (typically two applications, with a range of one to four) at these power settings appear to be safe in the colon. The water jet from the probes is extremely useful to clear the blood from the site and allow for precise localization and accurate probe application.

Another thermal coagulation technique is the use of coagulating forceps that directly grasp the vessel and apply soft coagulation current. This technique, which uses monopolar current, is commonly used to control bleeding in endoscopic submucosal dissection (ESD). The bleeding vessel is grasped with the forceps and "tented" towards the scope and a soft coagulation setting is used in short, one to two second bursts. The forceps can also be deployed in a closed fashion next to the bleeding vessel.

Other methods – Other methods to achieve hemostasis at the site of PPB include argon plasma coagulation (APC) and band ligation. Oozing of blood at the polypectomy site following removal of a large, sessile polyp (≥2 cm) can be controlled with APC, an alternative form of thermal coagulation which is discussed separately (picture 1). (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage", section on 'Piecemeal polypectomy'.)

Methods used to control bleeding in the setting of advanced endoscopic procedures (eg, endoscopic submucosal dissection) are discussed separately. (See "Overview of endoscopic resection of gastrointestinal tumors".)

DELAYED BLEEDING

Etiology — There are two major causes for delayed postpolypectomy bleeding (PPB):

Sloughing of eschar – PPB may start with sloughing of the eschar or scab that covered a blood vessel. Shedding of the scab is a normal part of the healing process and may be spontaneous or related to the passage of the fecal effluent across its surface.

Increasing zone of necrosis – Another cause of PPB is related to excavation of a zone of necrosis induced by the thermal energy used to resect the polyp and cauterize the polypectomy site. During the first few days after the procedure, the zone of necrosis excavates to the level of non-injured tissue, and it is usually deeper compared with what is visualized at the time of polypectomy. The necrosis usually involves some degree of the submucosa, which may lead to hemorrhage should it extend into a blood vessel.

Incidence and risk factors — Rates of delayed bleeding are generally low and range from 0.02 to 2 percent of patients who have polyps removed [9,14,15]. The risk of delayed postpolypectomy bleeding is related to polyp-specific factors and patient-specific factors [5,14-18]:

Polyp size – Bleeding risk increases with larger polyp size (ie, >1 cm, and particularly for polyps ≥2 cm) [15,16,19]. The incidence of bleeding is less than 1 percent for polyps ≤1 cm increases to 6.5 percent for those ≥2 cm [20,21]. Studies also suggest that the risk of delayed bleeding increases by 9 to 13 percent for every 1 mm increase in polyp diameter [19,22].

Polyp location – Bleeding risk is increased when polyps are removed from the right colon or cecum compared with more distal locations such as the sigmoid colon [19,21,23,24].

Anticoagulation status – Resuming anticoagulation (eg, warfarin, direct oral anticoagulant) after polypectomy is associated with an increased risk of delayed bleeding [22,25,26]. In a case-control study, patients with delayed bleeding had higher rates of anticoagulant use compared with patients with no bleeding (34 versus 9 percent) [22]. However, the risks of bleeding from resuming anticoagulation must be considered in the context of the thrombotic risk of withholding anticoagulation [27]. (See 'Optimizing preprocedure coagulation status' below.)

There is usually minor oozing of blood that occurs when the eschar sloughs from the polypectomy site, which can occur several days to several weeks after the procedure, when the anticoagulant has achieved its therapeutic effect. This expected minor oozing often occurs without overt bleeding, symptoms or clinical sequelae (eg, hypotension). However, bleeding from the site after eschar sloughing can be severe in an anticoagulated patient and may require urgent management, including fluid resuscitation, blood transfusion, hospitalization, and colonoscopy. (See 'Initial evaluation and resuscitation' below and 'Etiology' above.)

Use of aspirin or NSAIDS – There is either no or minimally increased risk of bleeding after polypectomy with aspirin or of nonsteroidal anti-inflammatory drug (NSAIDs). The available data are mixed regarding the potential risk for bleeding in the setting of NSAIDs or aspirin use [5,18]. In a meta-analysis of 11 studies including over 9000 patients who underwent colonoscopy and polypectomy, use of aspirin or NSAIDs was associated with an increased risk of postpolypectomy bleeding (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.2) [5]. In an earlier meta-analysis of three studies including over 4700 patients, the use of NSAIDs or aspirin was not associated with a significant increase in bleeding risk after polypectomy (OR 1.5, 95% CI 0.9-2.2) [18]. (See 'Postprocedure instructions' below.)

Clinical manifestations — Patients with delayed PPB often present in five to seven days after the procedure, but the timing of presentation can range from several hours to four weeks later [1,9,28,29]. A patient with PPB typically reports hematochezia (passage of maroon or bright red blood or clots per rectum) that may vary in volume and frequency (eg, ranging from a single episode to passage of blood every hour). Some patients exhibit signs of hypovolemia, such as tachycardia or hypotension, although many patients remain hemodynamically stable.

The initial hemoglobin in patients with acute postpolypectomy bleeding will typically be at the patient's baseline. In 24 hours or more following presentation, the hemoglobin will reflect the amount of blood loss.

Management

Initial evaluation and resuscitation — The initial evaluation and management of a patient with suspected delayed postpolypectomy bleeding occur in parallel and are similar to the approach for patients with lower gastrointestinal (GI) bleeding from other sources. Patients who have more than small, limited amounts of blood per rectum or who have symptoms of hypotension (eg, dizziness) within four weeks following polypectomy should be evaluated promptly.

Signs of hypovolemia (tachycardia or hypotension) are suggestive of hemodynamic instability, and initial laboratory testing includes a complete blood count, serum chemistries, and coagulation studies. Gastroenterology consultation should be obtained at the time of the patient’s presentation. The evaluation and management of patients with lower GI bleeding, including clinical assessment, fluid resuscitation, blood transfusion, and treatment of coagulopathies, are discussed separately. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Initial evaluation and management'.)

For patients with postpolypectomy severe bleeding resulting in hemodynamic instability (ie, tachycardia and/or hypotension that does not respond to resuscitation with fluid or blood), interventional radiology and surgery consults can be obtained to provide a multidisciplinary approach to further intervention. (See 'Subsequent interventions' below.)

Patients with ongoing bleeding

Planning for and timing of repeat colonoscopy — Patients with ongoing bleeding are prepared for and typically undergo colonoscopy after resuscitation and bowel preparation (typically within 24 hours of admission), while patients who stop bleeding do not require endoscopic examination [21]. (See 'Patients without ongoing bleeding' below.)

Based on clinical experience, the frequency with which patients pass bloody bowel movements is a good indicator of whether bleeding is ongoing. Bloody bowel movements that are frequent (ie, occurring every two hours) suggest active bleeding, while the cessation of bleeding from the polypectomy site is marked by minimal (eg, <50 mL bloody stool) or no stool output.

For hospitalized patients with ongoing postpolypectomy bleeding, we generally give bowel preparation with four liters of polyethylene glycol-electrolyte lavage solution taken orally prior to colonoscopy. Blood within the lumen of the colon has a laxative effect and may also help prepare the bowel for examination. Bowel preparation before colonoscopy is discussed in detail separately. (See "Bowel preparation before colonoscopy in adults".)

The optimal setting for an urgent colonoscopic examination is when the regular endoscopy staff are present, and that is usually during the daily hours of operation of the endoscopy unit. For example, if a patient presents with acute PPB in the evening or in the early hours of the morning, we first resuscitate the patient, give a bowel preparation, and monitor the patient while planning to perform the colonoscopy when the bowel preparation is complete.

Endoscopic interventions — Most patients with ongoing PPB can be managed with endoscopic therapy and infrequently require further intervention, such as surgery or angiographic methods (eg, selective embolization) [1,30]. (See 'Subsequent interventions' below.)

Endoscopic therapy is performed with placement of endoscopic clips or a thermal modality (eg, bipolar electrocautery[BICAP]), sometimes in combination with submucosal epinephrine injection, as previously discussed [1,30,31]. To minimize further potential mucosal injury from electrocautery, we typically use endoscopic clips to control bleeding at the polypectomy site when clip placement is technically feasible. (See 'Bleeding after sessile polyp removal' above and "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond".)

Submucosal injection with diluted epinephrine may be less effective in patients with delayed bleeding, in contrast to endoscopic injection therapy for immediate PPB. There is at least a mild to moderate degree of edema and induration at the polypectomy site within one to two days of polypectomy. This inflammatory response may cause obliteration of the separation of the layers of the colon wall, resulting in the inability for epinephrine injection to infiltrate into the tissue spaces, causing the injected fluid solution to run out of the needle hole at the injection site. Conversely, the induration and resulting increased thickness of the colon wall may make the use of thermal modalities safer, such that repeated applications of a heater probe, coagulating grasper or BICAP can be used to achieve hemostasis.

Another treatment option for PPB is hemostatic powder (Hemospray, Cook Endoscopy) that is delivered to the bleeding site through a catheter under endoscopic guidance and that can be used as monotherapy or in combination with other methods [32]. Hemostatic powder becomes cohesive and adhesive after coming into contact with moisture, forming a stable mechanical barrier at the site of bleeding. However, if hemostatic powder is deployed to stop active bleeding, another therapeutic modality should be performed to decrease risk of further bleeding. Delivery of and other applications for hemostatic powder are discussed separately. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Hemostatic sprays'.)

Subsequent interventions — Other options for achieving hemostasis for patients with delayed PPB that does not respond to initial management include angiographic therapy (eg, selective embolization) and surgery to remove the portion of the colon containing the polypectomy site. Angiographic therapy is preferred over surgery for patients with uncontrolled hemorrhage because it is effective but less invasive [33]. Super selective transcatheter arterial embolization with microcoils has been effective in controlling bleeding refractory to endoscopic therapy for PPB in case reports. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)

Surgery may be necessary for patients with persistent bleeding when other interventions fail. If only one polyp was removed, the probable location of the bleeding site will be known. If the site of PPB was identified during colonoscopy but the bleeding cannot be controlled using endoscopic methods, an endoscopic clip should be placed (if not already done) near the site to help with localization during subsequent intervention. The location of the clip in relation to the bleeding site (ie, whether clip was placed distal or proximal to the bleeding site) should be noted. Similarly, it is also reasonable to place a tattoo near the bleeding site to help with subsequent localization of the site. (See "Tattooing and other methods for localizing gastrointestinal lesions".)

A subtotal colectomy may be required if several polyps were removed in various areas of the colon, and a colonoscopic examination cannot identify the site of polypectomy bleeding. (See "Overview of colon resection".)

Patients without ongoing bleeding — For patients who have a few, small volume (ie, <50 mL) stools or no further bowel movements following their initial presentation, it is generally safe to defer colonoscopy while continuing clinical monitoring (eg, heart rate, blood pressure, serial hemoglobin levels, stool output). (See 'Initial evaluation and resuscitation' above.)

If bleeding has stopped without endoscopic intervention, it is unusual for it to resume. As a result, there is no need to repeat the colonoscopy to evaluate the presumed site of bleeding in a patient whose bleeding has stopped.

If bloody bowel movements recur during this period of observation, the patient should be given a bowel preparation and then colonoscopic examination can be performed. (See 'Patients with ongoing bleeding' above.)

MEASURES TO PREVENT BLEEDING

Optimizing preprocedure coagulation status — To minimize the risk of postprocedure bleeding, coagulation status is assessed and optimized in patients who are scheduled to undergo colonoscopy with possible polypectomy:

Patients on anticoagulants – Patients on chronic anticoagulation (eg, warfarin, direct oral anticoagulants) generally require interruption of anticoagulation prior to colonoscopy with removal of polyps >1 cm, and patients at high risk of thromboembolism may be managed with bridging therapy with a heparin product. Management of patients on anticoagulants in this setting is discussed separately. (See "Management of anticoagulants in patients undergoing endoscopic procedures".)

In addition, the use of cold snare polypectomy technique for polyps <1 cm reduces the risk of postpolypectomy bleeding (PPB) for patients on uninterrupted, chronic anticoagulation [34]. (See 'Polyps <1 cm' below.)

Anticoagulants and heparin bridge therapy are associated with higher rates of delayed PPB. In a study of 425 anticoagulated patients who discontinued warfarin prior to colonoscopy (and resumed it that evening) and 800 matched controls, the bleeding rate was higher in patients receiving warfarin compared with those not taking warfarin (2.6 percent versus 0.2 percent) [26]. Heparin bridge therapy, sometimes used to reduce thrombotic risk in high-risk patients while warfarin is being held, is associated with a higher rate of PPB [35,36]. In a study of 117 patients who underwent polypectomy, the rate of postpolypectomy bleeding was higher in patients receiving heparin bridge therapy compared with those who did not (20 versus 1 percent) [35].

Patients on aspirinAspirin therapy, especially if given for secondary prevention, is not interrupted prior to most endoscopic procedures.

For patients with a known polyp ≥2 cm who are undergoing colonoscopy for polyp removal, the approach depends on the endoscopist’s preference. Some endoscopists do not interrupt aspirin regardless of the indication [37], while others discontinue aspirin for five to seven days prior to large polyp resection only for patients who are NOT taking aspirin for secondary prevention (ie, those who do not have a history of cardiovascular or cerebrovascular disease). However, if a patient on uninterrupted aspirin therapy is found to have a large polyp during the index colonoscopy, the polyp should be removed at that time rather than having the patient return for a second colonoscopy after stopping aspirin. If the polyp is ≥2 cm, endoscopic clip placement may be performed to try to decrease the risk of bleeding. (See 'Incidence and risk factors' above and 'Patients with coagulopathy' below.)

Aspirin does not appear to increase the bleeding risk after small polyp resection, but may increase the risk after polypectomy requiring advanced techniques (eg, endoscopic mucosal resection). However, in patients taking aspirin for secondary prevention, the risk of thrombosis while holding aspirin may outweigh the bleeding risk. This is discussed elsewhere. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures", section on 'Aspirin'.)

Patients on other antiplatelet agents (excluding aspirin) – Most patients on antiplatelet therapy (excluding aspirin) generally discontinue the antiplatelet agent (eg, a P2Y12 receptor blocker such as clopidogrel) prior to elective colonoscopy with removal of previously identified polyps ≥1 cm [38]. However, we remove smaller polyps (<1 cm) in the setting of uninterrupted, chronic antiplatelet therapy. We usually continue aspirin and hold the P2Y12 platelet receptor blocker for elective colonoscopies, especially prior to removal of known large colon polyps. The risks of discontinuing anti-thrombotic agents must be weighed against the risk of postpolypectomy bleeding, and the management of these issues (including the approach to patients on dual antiplatelet therapy) is discussed in more detail separately. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures", section on 'Adjusting antiplatelet agents'.)

The magnitude of the effect of P2Y12 platelet receptor blockers on PPB may depend on coadministration of aspirin with the antiplatelet agent. A meta-analysis of five observational studies that included 574 patients on clopidogrel and 6169 control subjects found an increase in delayed PPB in patients on uninterrupted clopidogrel therapy with a relative risk (RR) of 4.7 (95% CI 2.4-9.2) [39]. However, other studies have shown that the increased risk of postpolypectomy bleeding is almost entirely in those patients who continue on both aspirin and a P2Y12 receptor blocker and is not observed in patients maintained on a P2Y12 receptor blocker alone [40,41].

Patients with disorders of hemostasis – Patients with disorders of hemostasis (eg, von Willebrand disease, thrombocytopenia) may require specific measures to prevent postpolypectomy bleeding (eg, factor replacement, platelet transfusion). Management of patients with disorders of hemostasis in this setting is discussed separately. (See "Gastrointestinal endoscopy in patients with disorders of hemostasis".)

Polypectomy techniques — Measures to prevent postpolypectomy bleeding may be aimed at decreasing the risk of immediate procedural bleeding or delayed bleeding. There are several techniques that can be applied prior to or following polyp resection for prevention of bleeding. However, there is limited data to guide the selection of technique. Thus, the decision to use a prophylactic measure depends upon the endoscopist’s experience, preference, and appraisal of the patient’s risk of bleeding. The following discussion summarizes our experience and preferences.

Polyps <1 cm — We use cold snare polypectomy for polyps ranging in size from 4 to 9 mm because this approach is effective and reduces the risk of PPB [42-45], while diminutive polyps (1 to 3 mm) can be removed with either a cold snare or cold biopsy forceps [46-48]. Cold polypectomy is a technique that does not require electric current, while hot snare polypectomy uses electrocautery. (See "Overview of colon polyps", section on 'Polypectomy'.)

The practice of using a cold snare in this setting is supported by clinical trials and observational data with low to moderate quality of evidence [44,45,49,50]. In a trial including 538 patients with a total of 796 polyps ranging from 4 to 9 mm in size, complete resection rates were similar for hot and cold snare techniques (97 versus 98 percent); however, there were only two episodes of delayed PPB, both of which occurred in the hot snare group (2 of 402 polyps, 0.5 percent) [44]. Similarly, in a retrospective study including 5371 patients with polyps <10 mm in diameter, propensity score matching was used to evaluate outcomes in polypectomies performed with hot snare (n = 2135) compared with cold snare (n = 2135) [45]. Hot snare polypectomy was associated with higher rates of PPB compared with cold snare polypectomy (0.56 versus 0.1 percent, OR 6.0, 95% CI 1.34-26.80).

In addition, data suggest that cold snare technique is associated with lower rates of PPB for anticoagulated patients [34,51]. In a trial of 70 patients on warfarin with a total of 159 polyps ≤1 cm, rates of delayed bleeding were lower in patients who underwent polypectomy with cold snare compared with snare electrocautery (0 versus 14 percent) [34]. In a trial of 184 anticoagulated patients with polyps <1 cm, rates of PPB were lower (but not statistically significant) in patients who had cold snare polypectomy while on uninterrupted anticoagulation (warfarin or direct oral anticoagulant) compared with patients who had hot snare polypectomy while being bridged with heparin (5 versus 12 percent, risk difference 7 percent [95% CI -1 to 16 percent]) [51].

Cold polypectomy technique is advantageous for removing polyps <1 cm because such polyps have small blood vessels that do not require electrocautery, which can result in an expanding zone of necrosis, leading to delayed PPB. (See 'Etiology' above.)

Polyps ≥1 cm

Endoscopic methods — We do not routinely use endoscopic clips or detachable loops to prevent delayed PPB for polyps <2 cm in size; however, we may use a prophylactic measure in selected patients (eg, those who require anticoagulation). (See 'Patients with coagulopathy' below.)

Options to decrease the risk of bleeding for polyps ≥1 cm include removing the polyp by piecemeal cold snare polypectomy, using clips to close the mucosal defect following removal of a sessile polyp or placing clips across the stalk, placement of a nylon loop around the stalk of a pedunculated polyp, or injecting epinephrine at the polypectomy site [52,53] (see "Endoscopic removal of large colon polyps", section on 'Polyp removal techniques'):

Endoscopic clips – Metal clips may be used to prevent postpolypectomy bleeding after removal of large polyps, but data regarding their efficacy are mixed [20,54-60]. We use endoscopic clips to treat bleeding but do not routinely apply them prophylactically following removal of polyps <2 cm [61]. However, we typically place clips following endoscopic mucosal resection of polyps ≥2 cm, particularly if they are located in the proximal colon (ie, hepatic flexure, ascending colon or cecum) [54,56,57]. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond", section on 'Postpolypectomy bleeding'.)

Endoscopic clips can be placed onto the base of a pedunculated polyp (the stalk should be able to be completely entrapped by the closed clips) close to the bowel wall (picture 2), and then the wire snare can be placed over the polyp but above the clip. It is important that the wire snare does not touch the metal clip, lest an aberrant current pathway be activated, with a potential burn of the colon wall [62].

Clip closure of the mucosal defect lowers the rate of PPB after removal of selected nonpedunculated polyps (eg, polyps ≥2 cm, proximal colon location). In a meta-analysis of nine trials including nearly 7200 colorectal lesions, clip closure of the mucosal defect after removing nonpedunculated polyps ≥2 cm lowered the rate of PPB compared with no clip closure (4 versus 8 percent; RR 0.51, 95% CI 0.33-0.78) [63]. In addition, clip placement lowered the PPB rate for proximal colon polyps compared with no clip (3 versus 6 percent; RR 0.53, 95% CI 0.35-0.81), while the PPB rate was not significantly different for polyps in the distal colon.

Detachable nylon loops A detachable nylon loop (also referred to as a detachable snare) can be placed around the stalk of a pedunculated polyp like a wire snare and tightened with a one-way silicone-rubber stopper (picture 3 and picture 4). The stopper prevents opening of the loop once it has been closed. Loops need to be carefully and progressively tightened under visual control as there is little tactile feedback, and it is possible to unintentionally shear through the polyp pedicle and induce bleeding. Proper placement of nylon loops appears to decrease the risk of bleeding [64,65], but their presence may make the subsequent polypectomy more difficult, and this is discussed separately. (See "Endoscopic removal of large colon polyps", section on 'Preventing bleeding'.)

We do not routinely place loops on polyp stalks because of the low risk of bleeding [9], but we may use loops prior to polypectomy when removing a pedunculated polyp in patients with a disorder of hemostasis (eg, von Willebrand disease) or in those who are unable to stop or need to resume anticoagulation. (See 'Patients with coagulopathy' below.)

Placement of the loop after polypectomy is usually easier than placement prior to polypectomy. The loop is deployed onto the residual stalk and left there for hemostasis. However, the resected pedicle may quickly flatten out, leaving no protuberant stalk on which to place the loop [66]. A two-channel endoscope can be used to grasp the bleeding site with forceps while placing a loop over the bleeding site to ligate the culprit blood vessel [67]. Similarly, it may also be possible to place the flexible loop into a transparent mucosectomy cap and, after suctioning the base of the polypectomy site into the cap, successfully deploy the loop on the residual pedicle [68].

There are two sizes of loops, with the smaller (2.5 cm in diameter) being best suited for capture of the postpolypectomy base, and the larger (4 cm in diameter) used prior to polypectomy. The nylon loops spontaneously slough in approximately four to seven days, leaving residual shallow ulcers.

Nylon loop or detachable snare placement is associated with a lower risk of PPB after removal of large polyps [64]. In a trial of over 300 patients with pedunculated polyps >1 cm, prophylactic placement of a detachable snare on the base of the polyp stalk was associated with lower rates of PPB compared with snare resection alone (2 versus 8 percent).

Submucosal injection of diluted epinephrine – Diluted epinephrine (1:10,000 or 1:20,000) can be added to saline solution that is injected into the stalk of a pedunculated polyp or into the base of a sessile polyp prior to removal. However, whether submucosal epinephrine injection should be used routinely is uncertain, given the low risk of immediate bleeding following polyp resection [23,69-71]. In a trial of 486 patients with a total of 561 large polyps (ie, >1 cm), there was no significant difference in rates of overall, immediate, or delayed bleeding, in patients who had polypectomy with submucosal injections of diluted epinephrine solution compared with patients who received submucosal injections of saline solution alone [23]. (See 'Bleeding after sessile polyp removal' above.)

Patients with coagulopathy — For patients with a coagulopathy or for those who must resume anticoagulation after removal of a polyp ≥1 cm, the risk of delayed bleeding may be reduced by the use of mechanical hemostatic tools such as endoscopic clips (picture 5) or nylon loops, although studies of this approach in anticoagulated patients are lacking. (See 'Polypectomy techniques' above.)

We use clips (for sessile or pedunculated polyps ≥1 cm) or nylon loops (for pedunculated polyps ≥1 cm) to close a postpolypectomy site in patients who must resume anticoagulation or who have bleeding diatheses (eg, thrombocytopenia) as a measure to decrease the risk of PPB. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond" and 'Endoscopic methods' above.)

Postprocedure instructions — Postprocedure instructions to minimize the risk of PPB focus on adjusting some medications and diet:

NSAIDs (including aspirin) – We advise patients who undergo colonoscopy with polypectomy to avoid aspirin (only if it is being given for primary prevention) and NSAIDs for 14 days after snare polypectomy. If aspirin is being taken for secondary prevention, we instruct patients to resume aspirin after the procedure. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures", section on 'Aspirin' and "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease".)

Diet – Postpolypectomy diet is not associated with delayed bleeding, and most patients are given no specific dietary restrictions. However, in our experience, patients who had immediate PPB in the setting of a large mucosal defect (eg, after removal of a polyp >2 cm) may be at higher risk for early delayed PPB. We selectively instruct such patients to have a liquid diet for 24 hours, followed by one day of soft, solid-textured foods prior to resuming a regular diet. (See 'Incidence and risk factors' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastrointestinal bleeding in adults".)

SUMMARY AND RECOMMENDATIONS

Immediate postpolypectomy bleeding – Immediate postpolypectomy bleeding (PPB) refers to the passage of blood that is not self-limited (eg, bleeding that persists for more than one minute after polypectomy) or that begins before the patient is discharged from the endoscopy unit. (See 'Definition' above.)

Most cases of immediate PPB can be managed during colonoscopy by the endoscopist. The technique for controlling bleeding depends upon the severity of bleeding, the type of polyp, and endoscopist's preference. (See 'Management' above.)

Delayed postpolypectomy bleeding – For patients who undergo polypectomy, the rate of delayed bleeding is generally low (ranging from 0.02 to 2 percent). The risk of delayed postpolypectomy bleeding is related to polyp-specific factors (eg, polyp size and location), procedure-specific factors (eg, hot versus cold snare technique), and patient-specific factors (eg, anticoagulation status). (See 'Incidence and risk factors' above.)

Initial evaluation – For patients with suspected delayed postpolypectomy bleeding, the initial evaluation and management occur in parallel and are similar to the approach for patients with lower gastrointestinal bleeding from other sources. Patients who have more than small amounts of blood per rectum or who have symptoms of hypotension (eg, dizziness) within four weeks following polypectomy should be seen promptly for further evaluation. (See 'Initial evaluation and resuscitation' above and "Approach to acute lower gastrointestinal bleeding in adults".)

Management – For most patients with ongoing PPB, endoscopic therapy (eg, placement of endoscopic clips) usually results in long-term hemostasis, and further intervention such as surgery or angiography with embolization is infrequently needed. (See 'Patients with ongoing bleeding' above.)

Preventive strategies – Measures to prevent PPB include:

For patients who are scheduled to undergo colonoscopy with possible polypectomy, we assess and optimize their preprocedure coagulation status to decrease the risk of postprocedure bleeding. (See 'Optimizing preprocedure coagulation status' above.)

For patients with polyps ranging in size from 4 to 9 mm, we suggest using a cold snare polypectomy technique because this approach is effective and reduces the risk of PPB compared with a hot snare technique (Grade 2C). For patients with diminutive polyps (1 to 3 mm), either a cold snare or cold forceps polypectomy technique can be used. (See 'Polyps <1 cm' above and "Overview of colon polyps".)

For patients with polyps ≥1 cm, cold snare polypectomy may be used, and endoscopic techniques applied prior to or following polyp resection (eg, placement of a clip or detachable nylon loop) may reduce the risk of PPB. The decision to use a particular prophylactic measure is individualized and depends on the endoscopist's preference and the patient's risk factors for bleeding (eg, anticoagulation status, polyp size, and polyp location). (See 'Polypectomy techniques' above and "Endoscopic removal of large colon polyps".)

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References

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