What is the risk of bleeding after polypectomy and how is it managed in patients taking anticoagulant medications such as warfarin (anticoagulant), aspirin (acetylsalicylic acid), and clopidogrel (antiplatelet)?

From the Guidelines

The risk of bleeding after polypectomy is approximately 1-6%, with delayed bleeding occurring up to 14 days post-procedure, and management of anticoagulant medications should be individualized based on the bleeding risk of the procedure and the patient's thromboembolic risk. According to the most recent and highest quality study 1, the incidence of post-polypectomy bleeding (PPB) ranges between 0.07%–1.7%, and delayed PPB is of particular importance in patients in whom antithrombotic therapy has been interrupted. The study also found that the use of endoscopic clips or submucosal injection of diluted epinephrine may reduce the risk of PPB, and caution is advised when using clips prior to excision for pedunculated polyps. Some key points to consider in managing anticoagulant medications include:

• For warfarin, it's typically recommended to discontinue the medication 5 days before high-risk procedures and resume it the evening after the procedure, with bridging therapy using low molecular weight heparin for patients at high thromboembolic risk 1.
• Aspirin can generally be continued for low-risk procedures but should be stopped 5-7 days before high-risk procedures unless the patient has a recent coronary stent.
• Clopidogrel should be discontinued 5-7 days before high-risk procedures, but this decision should be made in consultation with the prescribing physician, especially for patients with recent cardiac stents. After polypectomy, if bleeding occurs, management includes endoscopic treatment with clips, epinephrine injection, or thermal coagulation, along with volume resuscitation if needed. The timing of anticoagulant resumption post-bleeding should be individualized based on the severity of bleeding and the patient's thromboembolic risk, as suggested by 1 and 1. This approach balances the risk of procedural bleeding against the risk of thromboembolic events from medication discontinuation. It's also important to note that the risk of polypectomy on continued antiplatelet therapy has been studied, and aspirin monotherapy has been found to be safe in colonoscopic polypectomy 1. However, the risk of PPB in patients on clopidogrel therapy is increased, and the decision to continue or discontinue clopidogrel should be made on an individual basis, taking into account the patient's thromboembolic risk and the risk of bleeding associated with the procedure.

From the Research

Risk of Bleeding after Polypectomy

The risk of bleeding after polypectomy is a significant concern, especially in patients taking anticoagulant medications such as warfarin, aspirin, and clopidogrel. Several studies have investigated the incidence and risk factors for postpolypectomy bleeding in these patients.

Incidence of Postpolypectomy Bleeding

• The incidence of postpolypectomy bleeding varies depending on the anticoagulant medication used. A study published in 2018 found that the overall incidence of bleeding on antithrombotics was 1.19% 2.
• Another study published in 2022 found that the major postpolypectomy bleeding rate was 2.0% in patients taking aspirin and 18.2% in patients taking clopidogrel who continued their antiplatelet therapy 3.
• A study published in 2021 found that the delayed postpolypectomy bleeding rate was 1.6% in patients taking direct oral anticoagulants (DOACs) and 1.6% in patients taking clopidogrel 4.

Risk Factors for Postpolypectomy Bleeding

• Several risk factors have been identified for postpolypectomy bleeding, including:
  • Larger polyp size: A study published in 2018 found that patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < 0.001) 2.
  • Multiple polyps: The same study found that having multiple large polyps was a risk factor for bleeding (OR 2.92; P = 0.001) 2.
  • Restarting antithrombotics within 1 week postpolypectomy: A study published in 2008 found that resuming anticoagulation within 1 week following polypectomy was a risk factor for severe delayed postpolypectomy bleeding (OR 5.2; 95% CI 2.2-12.5; P < 0.001) 5.
  • Bridge anticoagulation: A study published in 2018 found that bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = 0.0001) 2.

Management of Anticoagulation after Polypectomy

• The management of anticoagulation after polypectomy varies, but several studies suggest that it is safe to resume anticoagulation or antiplatelet agents post-polypectomy 6.
• A study published in 2011 found that resuming anticoagulation or antiplatelet agents (warfarin, aspirin, and clopidogrel) post-polypectomy was safe and did not significantly affect the post-polypectomy rate of hemorrhage 6.
• However, another study published in 2022 found that continuous administration of antiplatelet agents was significantly associated with higher postpolypectomy bleeding in clopidogrel users, but not in aspirin users 3.