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Risk factors for delayed postpolypectomy bleeding: how to minimize your patients’ risk

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Secondary bleeding after colonoscopic polypectomy is a serious complication. Most studies show polyp size, location, and shape to be important risk factors but other factors may allow refinement of risk. The aim of this study is to look for other factors associated with delayed postpolypectomy bleeding.

Methods

This case-matched study compares patients who developed postpolypectomy bleeding with those who underwent uncomplicated polypectomy. Matching was performed for known risk factors: polyp size, location and shape, with a ratio of three controls to one subject.

Results

Postpolypectomy bleeding occurred in 19/494 patients with polyps >2.0 cm diameter (3.8 %) and 11/4161 patients with polyps <2.0 cm (0.3 %). There was a median interval of 3 days (range 0–9 days) from polypectomy to hemorrhage. Twenty-five patients were readmitted to this institution. Ten (40.0 %) were transfused and 19 (76.0 %) were re-colonoscoped, with 13 needing either cautery (n = 7) or adrenaline injection (n = 6). Ninety patients were selected as controls, matched for polyp size, location, and shape. Mean age at polypectomy was 69.9 ± 9.2 years for patients and 64.9 ± 12.2 for controls (p = 0.042); 63.3 % subjects were male, compared to 47.8 % of controls (p = 0.140). Univariate analysis showed that older age, piecemeal polypectomy, need for additional sedation, concurrent diverticulosis and intraprocedural bleeding were significantly associated with increased risk of delayed bleeding. The associations between delayed bleeding and additional sedation, concurrent diverticulosis and intraprocedural bleeding were confirmed by multivariate logistic regression analysis.

Conclusion

Difficult colonoscopy and intraprocedural bleeding identify patients with a particularly high risk of secondary postpolypectomy bleeding. Preventive measures should be considered in such cases.

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References

  1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61:69–90

    Article  PubMed  Google Scholar 

  2. Winawer SJ, Zauber AG, Ho MN, O’Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF et al (1993) Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup, N Engl J Med 329:1977–1981

    Article  CAS  Google Scholar 

  3. Manser CN, Bachmann LM, Brunner J, Hunold F, Bauerfeind P, Marbet UA (2012) Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study. Gastrointest Endosc 76:110–117

    Article  PubMed  Google Scholar 

  4. Iqbal CW, Cullinane DC, Schiller HJ, Sawyer MD, Zietlow SP, Farley DR (2008) Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 143:701–706, discussion 706–707

    Article  PubMed  Google Scholar 

  5. Schultz M, Davidson A, Donald S, Targonska B, Turnbull A, Weggery S, Livingstone V, Dockerty JD (2009) Gastroenterology service in a teaching hospital in rural New Zealand, 1991–2003. World J Gastroenterol 15:583–590

    Article  PubMed  Google Scholar 

  6. Cohen LB, Wecsler JS, Gaetano JN, Benson AA, Miller KM, Durkalski V, Aisenberg J (2006) Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 101:967–974

    Article  PubMed  Google Scholar 

  7. Rosen L, Bub DS, Reed JF 3rd, Nastasee SA (1993) Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 36:1126–1131

    Article  PubMed  CAS  Google Scholar 

  8. Dominitz JA, Eisen GM, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Raddawi HM, Vargo JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO (2003) Complications of colonoscopy. Gastrointest Endosc 57:441–445

    Article  PubMed  Google Scholar 

  9. Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ (2000) Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 51:690–696

    Article  PubMed  CAS  Google Scholar 

  10. Rabeneck L, Paszat LF, Hilsden RJ, Saskin R, Leddin D, Grunfeld E, Wai E, Goldwasser M, Sutradhar R, Stukel TA (2008) Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 135(1899–1906):1906 e1891

    Google Scholar 

  11. Watabe H, Yamaji Y, Okamoto M, Kondo S, Ohta M, Ikenoue T, Kato J, Togo G, Matsumura M, Yoshida H, Kawabe T, Omata M (2006) Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 64:73–78

    Article  PubMed  Google Scholar 

  12. Hui AJ, Wong RM, Ching JY, Hung LC, Chung SC, Sung JJ (2004) Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 59:44–48

    Article  PubMed  Google Scholar 

  13. Macrae FA, Tan KG, Williams CB (1983) Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 24:376–383

    Article  PubMed  CAS  Google Scholar 

  14. Kapetanos D, Beltsis A, Chatzimavroudis G, Katsinelos P (2012) Postpolypectomy bleeding: incidence, risk factors, prevention, and management. Surg Laparosc Endosc Percutan Tech 22:102–107

    Article  PubMed  Google Scholar 

  15. Barnert J, Messmann H (2009) Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6:637–646

    Article  PubMed  Google Scholar 

  16. Zuckerman MJ, Hirota WK, Adler DG, Davila RE, Jacobson BC, Leighton JA, Qureshi WA, Rajan E, Hambrick RD, Fanelli RD, Baron TH, Faigel DO (2005) ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 61:189–194

    Article  PubMed  Google Scholar 

  17. Sawhney MS, Salfiti N, Nelson DB, Lederle FA, Bond JH (2008) Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 40:115–119

    Article  PubMed  CAS  Google Scholar 

  18. Doniec JM, Lohnert MS, Schniewind B, Bokelmann F, Kremer B, Grimm H (2003) Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery? Dis Colon Rectum 46:340–348

    Article  PubMed  Google Scholar 

  19. Buddingh KT, Herngreen T, Haringsma J, van der Zwet WC, Vleggaar FP, Breumelhof R, Ter Borg F (2011) Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol 106:1119–1124

    Article  PubMed  Google Scholar 

  20. Church JM (2003) Avoiding surgery in patients with colorectal polyps. Dis Colon Rectum 46:1513–1516

    Article  PubMed  Google Scholar 

  21. Panteris V, Haringsma J, Kuipers EJ (2009) Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy 41:941–951

    Article  PubMed  CAS  Google Scholar 

  22. Yousfi M, Gostout CJ, Baron TH, Hernandez JL, Keate R, Fleischer DE, Sorbi D (2004) Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol 99:1785–1789

    Article  PubMed  Google Scholar 

  23. Rathgaber SW, Wick TM (2006) Colonoscopy completion and complication rates in a community gastroenterology practice. Gastrointest Endosc 64:556–562

    Article  PubMed  Google Scholar 

  24. Manocha D, Singh M, Mehta N, Murthy UK (2012) Bleeding risk after invasive procedures in aspirin/NSAID users: polypectomy study in veterans. Am J Med 125:1222–1227

    Article  PubMed  Google Scholar 

  25. Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Lichtenstein DR, Maple JT, Shen B, Strohmeyer L, Baron T, Dominitz JA (2009) Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 70:1060–1070

    Article  PubMed  Google Scholar 

  26. Singh M, Mehta N, Murthy UK, Kaul V, Arif A, Newman N (2010) Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 71:998–1005

    Article  PubMed  Google Scholar 

  27. Friedland S, Soetikno R (2006) Colonoscopy with polypectomy in anticoagulated patients. Gastrointest Endosc 64:98–100

    Article  PubMed  Google Scholar 

  28. Kim HS, Kim TI, Kim WH, Kim YH, Kim HJ, Yang SK, Myung SJ, Byeon JS, Lee MS, Chung IK, Jung SA, Jeen YT, Choi JH, Choi KY, Choi H, Han DS, Song JS (2006) Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 101:1333–1341

    Article  PubMed  Google Scholar 

  29. Streett SE (2007) Endoscopic colorectal cancer screening in women: can we do better? Gastrointest Endosc 65:1047–1049

    Article  PubMed  Google Scholar 

  30. Witte TN, Enns R (2007) The difficult colonoscopy. Can J Gastroenterol 21:487–490

    PubMed  Google Scholar 

  31. Oh SY, Sohn CI, Sung IK, Park DI, Kang MS, Yoo TW, Park JH, Kim HJ, Cho YK, Jeon WK, Kim BI (2007) Factors affecting the technical difficulty of colonoscopy. Hepatogastroenterology 54:1403–1406

    PubMed  Google Scholar 

  32. Anderson JC, Messina CR, Cohn W, Gottfried E, Ingber S, Bernstein G, Coman E, Polito J (2001) Factors predictive of difficult colonoscopy. Gastrointest Endosc 54:558–562

    Article  PubMed  CAS  Google Scholar 

  33. Hsieh YH, Lin HJ, Tseng GY, Perng CL, Li AF, Chang FY, Lee SD (2001) Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 48:1379–1382

    PubMed  CAS  Google Scholar 

  34. Dobrowolski S, Dobosz M, Babicki A, Dymecki D, Hac S (2004) Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 18:990–993

    Article  PubMed  CAS  Google Scholar 

  35. Shioji K, Suzuki Y, Kobayashi M, Nakamura A, Azumaya M, Takeuchi M, Baba Y, Honma T, Narisawa R (2003) Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 57:691–694

    Article  PubMed  Google Scholar 

  36. Li LY, Liu QS, Li L, Cao YJ, Yuan Q, Liang SW, Qu CM (2011) A meta-analysis and systematic review of prophylactic endoscopic treatments for postpolypectomy bleeding. Int J Colorectal Dis 26:709–719

    Article  PubMed  CAS  Google Scholar 

  37. Paspatis GA, Paraskeva K, Theodoropoulou A, Mathou N, Vardas E, Oustamanolakis P, Chlouverakis G, Karagiannis I (2006) A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 101:2805, quiz 2913

    Article  PubMed  CAS  Google Scholar 

  38. Harewood GC (2007) Prophylactic clip application after colonic polypectomy. Gastrointest Endosc 65:183, author reply 183

    Article  PubMed  Google Scholar 

  39. Sonnenberg A (2012) Management of delayed postpolypectomy bleeding: a decision analysis. Am J Gastroenterol 107:339–342

    Article  PubMed  Google Scholar 

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Disclosure

The authors declared no financial conflict of interest.

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Authors and Affiliations

  1. Department of Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA

    Xian-rui Wu, James M. Church, Awad Jarrar, Jennifer Liang & Matthew F. Kalady

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  1. Xian-rui Wu
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  2. James M. Church
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  3. Awad Jarrar
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  4. Jennifer Liang
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Correspondence to James M. Church.

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Wu, Xr., Church, J.M., Jarrar, A. et al. Risk factors for delayed postpolypectomy bleeding: how to minimize your patients’ risk. Int J Colorectal Dis 28, 1127–1134 (2013). https://doi.org/10.1007/s00384-013-1661-5

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