What is the management approach for a pedunculated (attached by a stalk) mass on the abdomen that bleeds?

Management of Pedunculated Abdominal Mass with Bleeding

For a bleeding pedunculated mass on the abdomen, immediate excision via hot snare polypectomy is the definitive treatment, with prophylactic mechanical ligation of the stalk using a detachable endoloop or clips strongly recommended for lesions with head ≥20 mm or stalk thickness ≥5 mm to prevent life-threatening hemorrhage. 1

Initial Assessment

Before attempting removal, evaluate the following critical characteristics:

• Head size and stalk thickness - These determine bleeding risk and need for prophylactic measures 2
• Surface features - Look for irregular architecture, mucosal depression, or radiating folds suggesting invasive malignancy 2
• Bleeding severity - Assess whether this is acute catastrophic bleeding, episodic major bleeding, or low-volume oozing 3

Prophylactic Bleeding Prevention (Critical Step)

For lesions with head ≥20 mm OR stalk thickness ≥5 mm, prophylactic mechanical ligation is mandatory to reduce both immediate and delayed post-polypectomy bleeding. 1, 2

Recommended prophylactic techniques:

• Detachable endoloop (preferred) - Apply to the base of the stalk to strangulate the feeding vessel, creating an ischemic purple appearance before transection 1
• Prophylactic clips - Equally effective as endoloop, though technically more difficult with thick stalks (>10 mm) and may cause thermal injury 1
• Epinephrine injection - Consider 4-8 mL of 1:10,000 epinephrine into both polyp head and stalk as an adjunct to reduce size and improve en bloc resection 1, 2

Important caveat: Studies show endoloop and clips have similar bleeding rates (5.7% vs 5.1%), but loops may fail in very short stalks (<15 mm) due to slippage. 1

Resection Technique

Hot snare polypectomy is the standard of care for pedunculated lesions ≥10 mm. 1

Technical execution:

• Transect at the middle to lower stalk - This provides adequate tissue for histologic assessment of potential stalk invasion 1, 2
• Snare placement - Position the electrocautery snare above the endoloop with sufficient room to prevent loop slippage after transection 1
• Tighten the snare maximally - Make the snared plane smaller than the looped plane to ensure the loop remains secure 1

Specimen Handling (Critical for Pathology)

Retrieve the specimen en bloc without dividing the polyp head - This is essential for accurate margin assessment, especially if invasive carcinoma is present. 1, 2

Proper orientation technique:

• Flatten and fix the specimen with thin needles on wood or Styrofoam block before formalin immersion 1
• Mark or pin the stalk to enable accurate pathologic staging of invasion depth 1
• Serial sectioning at 2-mm intervals perpendicular to the resection plane 1

Post-Resection Management

• Inspect the resection site carefully for immediate bleeding or perforation risk 2
• Consider tattoo placement 3-5 cm distal (anal side) to the resection site using sterile carbon particle suspension if future localization may be needed 1, 2
• Document thoroughly including tattoo material, volume, and position in the endoscopy report 2

Bleeding Complications and Risk Factors

Immediate bleeding rates with prophylaxis range from 0-6.2%, while delayed bleeding ranges from 0-9.5%. 1

High-risk features requiring extra vigilance:

• Stalk thickness >10 mm - Associated with significantly greater bleeding risk 1
• Head size 35-50 mm - May be difficult to loop, requiring clip-assisted resection 1
• Left-sided location - Right-sided polyps have 61% reduced bleeding risk compared to left-sided 4

Without prophylactic measures, delayed bleeding rates can reach 9.5% compared to 0% with endoloop. 1

Common Pitfalls to Avoid

• Do not use hot snare alone for large pedunculated lesions without prophylactic ligation - this dramatically increases bleeding risk 1
• Do not divide the polyp head for easier retrieval - this compromises margin assessment and staging 1
• Do not place clips on very thick stalks (>10 mm) without considering larger clips or alternative techniques 1
• Do not transect too high on the stalk - inadequate tissue prevents proper histologic assessment of invasion 1