Immediate (intraprocedural) hemorrhage

Constricting the residual stump with the snare and holding pressure can usually control immediate bleeding following transection of a pedunculated polyp with a thick stalk. If significant bleeding recurs following snare loosening, reconstricting the stalk for an additional period of time may result in hemostasis or, alternatively, dilute epinephrine (1:10,000 solution) can be injected in the base of the stump to reduce or stop bleeding and enable clearing of the field of view for more definitive therapy, such as placement of clips, a detachable snare (endoloop), or direct suture ligation.

In the situation where the residual stalk is too short to grasp with the electrosurgical snare or an endoloop, several hemostatic measures can be used, alone or in combination. Dilute epinephrine can be injected in and around the bleeding point, but care should be undertaken to avoid overinjection on the aboral side to avoid lifting the lesion away from view and placing it in a difficult position for subsequent therapy. The use of epinephrine is only a temporary measure and this should be followed by more definitive therapy. When technically feasible, the application of mechanical hemostatic devices is preferable because they do not extend the depth of tissue injury, which occurs with the use of thermal devices. Endoscopic clips can be placed directly on the bleeding point or on the residual stalk. Alternatively, a detachable snare can be used if access to and length of the residual stalk are favorable. If thermal probes are used, coaptive coagulation for 3 to 5 seconds is recommended at settings of 15 J for the heater probe and 12 to 15 W for the bipolar coagulation probe. The tip of the snare can also be used to control bleeding, but caution using this technique is warranted to avoid deep monopolar thermal injury. The Coagrasper device (Olympus Corp., Tokyo, Japan) is a monopolar coagulation forceps designed for grasping, tenting, and sealing of nonbleeding and bleeding vessels. Although it is used primarily during endoscopic submucosal dissection (ESD) for coagulation of submucosal vessels, it can be effective at grasping and sealing the bleeding vessel atop the resected stalk or polypectomy base, provided the grasped tissue can be tented.

Treatment of bleeding that occurs during en bloc or piecemeal EMR may not be necessary (eg, mild transient oozing at the resection edge). Endoscopic therapy should be reserved for active bleeding that interferes with completion of the procedure, or persistent oozing that has not ceased by the end of the procedure. An endoscope with forward water jet irrigation is helpful to precisely identify the location of the bleeding point. An actively bleeding vessel within an EMR defect is best treated with the grasping coagulation forceps (Coagrasper) using a soft coagulation mode at a power setting that produces prompt tissue coagulation (this can vary depending on the power setting [30–60 W] and type of electrosurgical unit; [CR] ) or with clip placement ( Fig. 2 ), with or without prior epinephrine injection. Clip placement, however, should be avoided if it has the potential to interfere with completion of resection. Argon plasma coagulation and contact thermal probes can extend the depth of tissue injury and should be used with caution.

( A ) Active bleeding following en bloc EMR of rectal polyp. ( B ) Hemostasis achieved following clip placement.

Delayed hemorrhage

In the setting of delayed postpolypectomy hemorrhage, the basic tenets regarding management of gastrointestinal (GI) bleeding should be followed, including triage to the appropriate service (ward or intensive care unit) based on the severity of bleeding and patient comorbidities, fluid and blood transfusions as appropriate, withholding anticoagulation and antiplatelet agents, and correction of coagulopathy if present.

Patients in whom bloody bowel movements have ceased at the time of admission can usually be managed conservatively because rebleeding is uncommon. If there are no signs of ongoing bleeding during administration of the colon preparation, colonoscopy may be deferred with the exception of patients requiring prompt resumption of antithrombotic therapy. In patients in whom bleeding recurs during observation or in those with ongoing bloody stools, urgent colonoscopy should be performed.

The significance and rebleeding rates of stigmata of recent hemorrhage found in postpolypectomy ulcer beds are not as well studied as those related to bleeding peptic ulcers. In general, the ulcer experience is translatable to the postpolypectomy ulcer. Postpolypectomy ulcers with clean bases or flat, pigmented spots do not require intervention. Pigmented protuberances (visible vessels), adherent clots, and active bleeding require endoscopic therapy. Clip placement or thermal therapy, alone or in combination with epinephrine injection, can be used to treat the underlying bleeding stigmata. Mucosal clips can be applied directly on the vessel or the entire postpolypectomy defect ( [CR] ). The latter may not be possible because of induration of the polypectomy base margins ( [CR] ). Similarly, it may be difficult for the Coagrasper device to grasp and tent a visible vessel within the indurated ulcer bed. This can result in avulsion of the vessel with subsequent bleeding. Some of these lesions may be amenable to placement of an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) ( [CR] ), but practical issues may limit the use of this device because removal of the endoscope is required for loading of the OTSC. Similarly, direct suture ligation may be performed after withdrawing the colonoscope (OverStitch; Apollo Endosurgery, Austin, TX), provided the bleeding site can be reached with a double-channel upper endoscope. An indurated polypectomy base provides a safety cushion for the use of contact thermal probes. These modalities may be more effective in this setting (see [CR] ). A hemostatic spray (Hemospray; Cook Medical Inc, Bloomington, IN) is effective in active bleeding but is not available in the United States.

Endoscopic therapy is usually successful in postpolypectomy bleeding. If bleeding cannot be controlled at the time of endoscopy, salvage angiographic embolization should be considered as the next step. Endoscopically placed clips are effective markers of the bleeding site and facilitate subsequent supraselective angiographic embolization using microcoils to minimize the risk of colonic ischemia. Surgical intervention for torrential postpolypectomy hemorrhage is a rare occurrence.