A polypectomy is the procedure for removing growths called polyps from the lining of the colon to prevent colorectal cancer. While highly effective, post-polypectomy bleeding (PPB) is the most frequently reported complication, occurring where the polyp was attached. Bleeding can happen immediately during the procedure, or it may manifest as delayed post-polypectomy bleeding (DPPB), which can appear days after the patient has left the facility. The average onset for delayed bleeding is typically five to seven days after the procedure, though it can occur up to 30 days later.
Recognizing Severe Post-Procedure Bleeding
Patients must distinguish between minor, expected spotting and a significant hemorrhage that requires immediate medical attention. Scant spotting or a small amount of blood mixed with stool is common in the days following the procedure and often resolves without intervention. Passing a large volume of bright red blood or dark, maroon-colored stools (hematochezia) is a sign that bleeding is more substantial.
Patients should be aware of symptoms indicating significant blood loss, including passing blood clots or experiencing signs of shock. These symptoms include feeling dizzy or light-headed, fainting (syncope), or developing severe abdominal pain. If bleeding is profuse or accompanied by systemic symptoms like a fast heart rate or confusion, it signals a medical emergency. Delayed post-polypectomy bleeding is the most prevalent major complication, often occurring when the protective eschar (scab) at the resection site detaches prematurely. About half of the patients admitted to the hospital with delayed bleeding require a blood transfusion, highlighting the potential severity of this complication.
Immediate Patient Management and Care
Upon noticing significant bleeding, the first step is to contact the physician who performed the procedure or seek immediate care at an emergency department. Communicating the amount and frequency of bleeding, along with associated symptoms like dizziness or abdominal pain, allows medical personnel to quickly triage the situation. It is beneficial to have a copy of the endoscopy report available, as it contains specific details about the size and location of the removed polyp.
Patients should immediately rest and avoid any strenuous activity or heavy lifting, as physical exertion can exacerbate bleeding. Dietary adjustments, such as temporarily switching to clear liquids or soft foods, may be recommended to reduce irritation to the colon. Hydration is also important to maintain overall stability.
A crucial step is the temporary discontinuation of certain medications, but only if directed by a healthcare professional. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, as well as antiplatelet agents and anticoagulants (blood thinners), interfere with the body’s natural clotting process. Unless instructed otherwise by the medical team managing the bleeding, these medications should be temporarily paused to allow the blood to clot more effectively at the wound site.
Clinical Techniques for Hemostasis
When a patient presents with significant bleeding, the primary goal of the gastroenterologist is to achieve hemostasis, or the stopping of blood flow, typically through a repeat colonoscopy. Endoscopic intervention successfully controls the majority of post-polypectomy bleeding episodes by sealing the compromised blood vessel at the detachment site.
One common technique is injection therapy, which involves injecting a solution directly into the submucosa around the bleeding site. A diluted solution of epinephrine is commonly used because it causes localized vasoconstriction, constricting the small blood vessels. The mechanical pressure from the injected fluid also helps to compress the bleeding vessel, which immediately slows or stops the hemorrhage.
Thermal coagulation uses heat energy to cauterize and seal the blood vessel, closing the wound. This can be achieved using various methods, including bipolar cautery or hemostatic forceps, which apply heat directly to the tissue. Argon plasma coagulation (APC), a non-contact thermal method, uses an ionized gas to deliver heat to the bleeding surface, creating a superficial seal on the mucosal defect.
Mechanical closure methods offer a physical means of stopping the bleeding by closing the mucosal defect. Endoscopic clips (hemoclips) are small metal devices deployed through the endoscope to pinch the edges of the wound together, providing immediate and durable closure. For larger or more complex defects, multiple clips may be required to ensure complete hemostasis. Detachable loops or bands may also be used, particularly for larger polyps, to ligate the base of the lesion.
Minimizing Future Bleeding Risk
Preventing post-polypectomy bleeding begins with identifying and managing known risk factors prior to the procedure. The size of the removed polyp is a significant predictor, with lesions greater than 10 millimeters, and especially those over 20 millimeters, carrying a higher risk of delayed bleeding. Polyps located in the right side of the colon, which has a thinner wall, and those with a sessile (flat) or large stalk morphology also increase the likelihood of hemorrhage.
Patient-specific factors also contribute to risk, including advanced age, the presence of chronic diseases like cardiovascular or renal disease, and the use of antithrombotic agents. For patients taking anticoagulants or antiplatelet medications, pre-procedure planning is necessary to balance the risk of bleeding against the risk of a thromboembolic event. The timing of discontinuation and resumption must be carefully managed by the physician.
The technique used for removal is also a modifiable factor in preventing bleeding. In high-risk cases, such as the removal of large polyps, prophylactic placement of hemoclips or the use of specific electrosurgical current settings may be employed during the initial procedure. Following the polypectomy, adherence to post-procedure guidelines, including a temporary restriction on heavy lifting or strenuous activity, is essential to allow the wound site to heal without disruption.