Hemorrhage following colonoscopic polypectomy

The conundrum of lower gastrointestinal bleeding

Acute massive hematochezia provides one of the greatest diagnostic and therapeutic challenges to the physician. Although most patients stop bleeding spontaneously and further evaluation can be carried on with less urgency, 10% to 15% require urgent diagnostic and therapeutic procedures. Clearly, the least invasive effective solution to the bleeding problem is generally the best, although in some cases, emergency undirected surgery may be necessary. Subtotal colectomy can be done with acceptable morbidity and mortality in this situation, provided that the surgeon is confident of a colonic source of the bleeding. An understanding of the strategies outlined above encourages the management of such patients with an eye to maximizing therapeutic benefit while minimizing morbidity.

Endoscopic resection of large pedunculated colorectal polyps using a detachable snare

BACKGROUND

Colonoscopic resection of pedunculated polyps with heads 1 cm or greater in diameter is difficult because of the risk of bleeding. To minimize this complication, we used a detachable snare that allowed endoscopic ligation of the stalk of a large pedunculated polyp and evaluated its safety and effectiveness in comparison with conventional endoscopic snare polypectomy.

METHODS

Patients with pedunculated polyps with heads 1 cm or greater in diameter were randomly assigned to colonoscopic polypectomy with (N = 47) or without (N = 42) a detachable snare. Arterial pumping bleeding immediately after colonoscopic polypectomy or hematochezia resulting in a 10% or greater drop in hematocrit was defined as "bleeding."

RESULTS

No bleeding occurred during or after polypectomy with a detachable snare, but bleeding occurred significantly more frequently (five patients, 12%) without a snare. Moreover, the use of a detachable snare reduced the duration of hospitalization after polypectomy.

CONCLUSIONS

Colonoscopic polypectomy with a detachable snare may be safer than conventional polypectomy without a detachable snare for resection of large, pedunculated polyps.

Postpolypectomy colonic hemorrhage

PURPOSE

This study was undertaken to evaluate the incidence, diagnostic methods, and treatment of hemorrhage occurring after colonoscopic polypectomy.

METHODS

A retrospective chart review was conducted of 12,058 patients who underwent colonoscopy at an academic referral center between January 1989 and July 1993. Of these, 6,365 patients required polypectomies or biopsies.

RESULTS

After these procedures, 13 patients (0.2 percent) developed lower gastrointestinal hemorrhage requiring hospitalization. All bleeding episodes occurred within 12 days of polypectomy or biopsy (mean = 8 days). Twelve patients (92 percent) underwent technetium-tagged red blood cell scintigraphy, which localized bleeding in four patients (31 percent). In the eight patients with normal scintigrams, hemorrhage did not recur, and no further evaluation was performed. Five patients (38 percent) underwent arteriography. Arteriogram was positive in two of four patients with positive scintigrams, and bleeding was controlled with selective vasopressin infusion. The fifth patient had arteriography without prior diagnostic studies because of massive hemorrhage; the bleeding site was identified and controlled with selective vasopressin infusion. Three patients had lower gastrointestinal endoscopy, with endoscopic identification of bleeding site in two patients, and endoscopic electrocautery controlled the bleeding in one patient. In the 13 patients with hemorrhage, cessation of bleeding occurred with intestinal rest and hydration in nine patients (69 percent), selective vasopressin infusion in three patients (23 percent), and endoscopic electrocautery in one patient (8 percent). Eight patients (62 percent) required blood transfusion with a mean of 4.8 units (excluding one patient on warfarin sodium who required 14 units of blood). No patient required surgical intervention.

CONCLUSIONS

Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.

Endoscopic and surgical complications of work-up in screening for colorectal cancer

BACKGROUND AND PURPOSE

In an ongoing randomized screening study of 68,306 patients for early detection of colorectal neoplasm, those with positive Hemoccult II tests (Smith Kline Diagnostic, Sunnyvale, CA) were examined with a flexible sigmoidoscope (FS; 60 cm) and double-contrast barium enema (DCE). The aim of this study was to determine the rate of complications to the work-up.

METHODS

A total of 2,108 FS, 1,987 DCE, 190 colonoscopies, and 104 laparotomies were performed because of a positive Hemoccult.

RESULTS

One patient's large bowel was perforated during diagnostic endoscopy. Four perforations of the large bowel occurred during endoscopic polypectomy (0.8 percent of 513 adenomas removed), and one case of bleeding occurred 12 days after polypectomy. No complications occurred in connection with the 1,987 DCE. Five of 104 laparotomized patients underwent relaparotomy, 3 after removal of a colorectal carcinoma, and 2 of 4 patients with diverticular disease. All five patients healed but required a longer stay at the hospital.

CONCLUSIONS

Complications occurred in 0.3 percent of the endoscopies, and 5 percent of patients had to undergo laparotomy again. No mortality occurred. If mortality attributable to colorectal cancer will decrease because of screening, we find the complication rate is acceptable.