From the Guidelines
Four patient-related factors that increase the risk of post-polypectomy delayed bleeding include advanced age, use of anticoagulant or antiplatelet medications, comorbidities such as cardiovascular disease or chronic kidney disease, and a history of previous bleeding disorders. These factors are supported by recent studies, including a 2020 study published in Gastroenterology, which found that significant risk factors for post-polypectomy bleeding include polyp size ≥10 mm, pedunculated lesions with thick stalks, laterally spreading tumors (LSTs), right-sided colonic lesions, use of anticoagulants, and patient comorbidities, such as cardiovascular or chronic renal disease 1.
Patient-Related Factors
- Advanced age: Older patients have more fragile blood vessels and impaired healing mechanisms, making them more susceptible to delayed bleeding complications, as noted in a 2009 study published in the Journal of the American College of Cardiology 1.
- Use of anticoagulant or antiplatelet medications: Patients taking medications like warfarin, direct oral anticoagulants (DOACs), aspirin, or clopidogrel have altered coagulation pathways that can lead to prolonged bleeding even after initial hemostasis appears adequate, as highlighted in a 2016 study published in Gut 1.
- Comorbidities: Significant comorbidities, especially those affecting circulation or kidney function, can impair normal clotting mechanisms and tissue repair, increasing the risk of delayed bleeding, as discussed in a 2015 study published in Gut 1.
- History of previous bleeding disorders: Patients with inherited or acquired bleeding disorders such as hemophilia, von Willebrand disease, or thrombocytopenia have baseline abnormalities in their clotting systems that predispose them to delayed bleeding events.
Clinical Implications
Clinicians should carefully assess these risk factors before performing polypectomy and consider modified techniques, prophylactic hemostatic measures, or closer post-procedure monitoring for high-risk patients, as recommended by the US Multi-Society Task Force on Colorectal Cancer in 2020 1. The use of endoscopic clipping of post-polypectomy defects >20 mm has been shown to reduce the overall risk of delayed hemorrhage, particularly in lesions in the proximal colon 1.
From the Research
Patient-Related Factors for Post-Polypectomy Delayed Bleeding
The following patient-related factors are associated with an increased risk of post-polypectomy delayed bleeding:
- Use of anticoagulants, such as warfarin and direct oral anticoagulants (DOACs) 2, 3, 4, 5
- Male gender 3
- Higher Charlson comorbidity index (CCI) 2
- Higher CHADS2 score 2
Anticoagulant-Related Factors
The risk of post-polypectomy bleeding varies among different types of anticoagulants:
- Warfarin is associated with a higher risk of post-polypectomy bleeding compared to some DOACs, such as apixaban 5
- Dabigatran and rivaroxaban are associated with a higher risk of post-polypectomy bleeding compared to apixaban 5
- Edoxaban may be safe with short-term withdrawal in patients undergoing endoscopic snare resection of colorectal polyps 3
- Bridge anticoagulation is associated with an increased risk of post-polypectomy bleeding 2, 4, 6
Procedure-Related Factors
The following procedure-related factors are associated with an increased risk of post-polypectomy bleeding: