What is the management of bleeding after colonoscopy with snare (surgical removal of a polyp using a snare) polypectomy?

Management of Bleeding After Colonoscopy with Snare Polypectomy

For bleeding after colonoscopy with snare polypectomy, endoscopic management is the first-line treatment approach, with specific techniques including resnaring the stalk for early bleeding or using injection therapy with adrenaline followed by thermal or mechanical therapy for delayed bleeding. 1

Classification of Post-Polypectomy Bleeding

Post-polypectomy bleeding can be classified into two main types:

1. Early/Immediate Post-Polypectomy Bleeding

   • Occurs during or immediately after the procedure
   • Typically arterial in nature
   • Results from inadequate hemostasis of blood vessels in the polyp stalk
   • Accounts for approximately 2-8% of cases of acute lower gastrointestinal bleeding 1

2. Delayed Post-Polypectomy Bleeding

   • Occurs up to 15 days after polypectomy
   • Results from sloughing of the eschar at the polypectomy site
   • Usually self-limited in >70% of cases
   • Mean presentation time is 5 days post-procedure 2

Management Algorithm

1. Early/Immediate Bleeding Management:

• First-line approach: Resnare the stalk of the polyp and apply pressure 1
• Technical parameters for active polyp stalk bleeding:
  • Bipolar coagulation: Large probe, 16-20W power, 1-2s pulse duration
  • Heater probe: Large probe, 15-20J power, moderate pressure
  • Endpoint: Bleeding stops 1
• Consider: Injection with 1:10,000 adrenaline prior to endoscopic coagulation 1

2. Delayed Bleeding Management:

• Initial assessment: Evaluate hemodynamic stability and resuscitate if necessary 3
• Endoscopic therapy options:
  • Injection therapy with adrenaline followed by thermal therapy
  • Endoscopic clipping devices
  • Loop ligation of remaining polyp stalk (if applicable)
  • Endoscopic band ligation 1
• Technical parameters for delayed polypectomy bleeding:
  • Bipolar coagulation: Large or small probe, 12-16W power, 1-2s pulse duration
  • Heater probe: Large probe, 10-15J power, moderate pressure
  • Endpoint: Bleeding stops or visible vessel flattens 1

Risk Factors for Post-Polypectomy Bleeding

• Polyp size ≥10 mm
• Pedunculated lesions with thick stalks
• Laterally spreading tumors (LSTs)
• Right-sided colonic lesions
• Use of anticoagulants
• Patient comorbidities (cardiovascular or chronic renal disease) 1

Prophylactic Measures

• For pedunculated lesions: Prophylactic mechanical ligation of the stalk with a detachable loop or clips is recommended for lesions with head ≥20 mm or stalk thickness ≥5 mm 1
• For large lesions: Consider prophylactic closure of resection defects ≥20 mm in the right colon when feasible 1
• Electrocautery choice: Use blended rather than pure cutting electrocautery currents in polypectomy snare to reduce risk of early bleeding 1

Special Considerations

Anticoagulant Management

• Patients on anticoagulants require individualized assessment balancing the risks of interrupting anticoagulation against the risks of significant bleeding 1
• Resumption timing should be based on bleeding risk assessment:
  • Some studies show <1% bleeding rate when warfarin is restarted on the same day
  • Other studies found increased risk when restarted within 7 days 2

Follow-up After Bleeding Episode

• Close monitoring for recurrent bleeding is essential
• For patients who had piecemeal EMR, follow-up colonoscopy should be performed within 2-6 months due to high rates of incomplete resection and early recurrence 2
• Recurrence rates increase with longer follow-up periods: 18.4% at 6 months, 23.1% at 12 months, and 30.7% at 24 months 2

Patient Instructions

• Seek immediate medical attention for:
  • Severe abdominal pain or distension
  • Fever over 100.4°F (38°C)
  • Signs of peritonitis
  • Significant rectal bleeding 2
• Avoid strenuous activity for 1 week
• Resume normal activities gradually as tolerated 2

Common Pitfalls and Caveats

1. Delayed recognition: Bleeding may occur up to 15 days after the procedure; patients should be informed about this risk 2
2. Inadequate resuscitation: Hemodynamic stabilization should precede endoscopic evaluation in severe cases 3
3. Cecal lesions: Extra care must be taken when treating lesions in the cecum to avoid perforation 1
4. Visible residual tissue: Avoid using ablative techniques on endoscopically visible residual tissue as they increase risk of recurrence 1

By following this structured approach to post-polypectomy bleeding management, clinicians can effectively address this common complication while minimizing morbidity and mortality.