A cold forceps biopsy is the removal of a small tissue sample using a hinged, cup-shaped grasping instrument passed through an endoscope, without any electrical current or heat. The “cold” distinguishes it from the “hot” biopsy technique, which applies electrocautery through the same forceps to burn and cut tissue simultaneously. Because no heat is involved, the collected specimen arrives at the pathology lab largely free of thermal damage, making it easier for a pathologist to read the cellular architecture under a microscope. It is one of the most commonly performed procedures in gastrointestinal endoscopy, used millions of times a year for everything from sampling suspicious stomach lining to removing tiny colon polyps.
How the Procedure Actually Works
During an endoscopy or colonoscopy, the physician threads a long, thin cable with a small set of jaws at its tip through the working channel of the scope. When the jaws reach the target tissue, they open, press against the surface, and snap shut, pinching off a fragment typically a few millimeters across. The physician then withdraws the forceps, drops the specimen into a container of preservative fluid (usually formalin), and can repeat the process as many times as needed. In some settings, the endoscopist takes multiple passes to ensure enough tissue is collected. One study of ultrasound-guided forceps biopsy, for instance, described repeating the biopsy up to six times to guarantee adequate samples from a submucosal lesion.1Thieme Medical Publishers. Endoscopic ultrasound-guided forceps biopsy from upper gastrointestinal subepithelial lesions using a forward-viewing echoendoscope
The tissue fragment then goes to a histology lab, where it is embedded in wax, sliced into extremely thin sections, stained, and placed on glass slides. A pathologist examines the slides to look for signs of inflammation, infection, precancerous changes, or cancer. The whole point of the biopsy is to get a piece of tissue that faithfully represents what is happening in the body, so anything that distorts the specimen, like heat artifact, makes the pathologist’s job harder or even impossible.
Why Skipping the Heat Makes a Real Difference
Hot biopsy forceps were popular for decades because the electrical current could simultaneously cauterize the biopsy site and reduce bleeding. The trade-off, though, was damage to the very specimen physicians needed to examine. A study comparing cold and hot biopsy specimens found that cautery damage, architectural distortion, and tissue fragmentation all occurred significantly more often in polyps removed with the hot technique.2PubMed. Histological quality of polyps resected using the cold versus hot biopsy technique In practical terms, this means the pathologist sometimes could not tell whether a polyp was completely benign or harbored early abnormal cells, because the heat had cooked the edges of the sample.
Research looking specifically at small colorectal polyps confirmed the scale of the problem. When jumbo cold forceps were compared with hot biopsy forceps, over 93% of cold forceps specimens showed no cautery damage or crush artifact at all, compared to fewer than 9% of hot biopsy specimens.3PubMed. The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps That gap is striking. It means specimens from cold forceps almost always gave the pathologist a clean, readable sample, while hot biopsy specimens frequently did not.
These findings helped drive a broader shift in practice. Data show that hot biopsy forceps were once commonly used for smaller colon polyps but that recognition of increased risks of thermal injury, delayed bleeding, and decreased specimen quality led to a steady decline in their use.4PubMed Central. A cooling off period: decline in the use of hot biopsy forceps technique in colonoscopy in the U.S. Medicare population 2000–2019 In many endoscopy units today, the hot technique has essentially been replaced for routine biopsies.
Forceps Design and Why Size Matters
Not all cold biopsy forceps are identical. They come in different cup sizes and configurations, and these design choices affect the specimen the pathologist receives. Standard forceps have smaller oval cups, while “jumbo” or “large-capacity” forceps have wider jaws that can grab a bigger bite of tissue. Some forceps also include a small central needle (sometimes called a spike) that anchors into the tissue before the cups close, helping to secure a deeper sample.
A comparison of standard and large-capacity forceps found that the larger versions obtained significantly bigger specimens overall. Interestingly, the needle versions of each size obtained significantly deeper biopsies than their non-needle counterparts, while simply making the cups larger did not reliably increase depth on its own.5Gastrointestinal Endoscopy. Standard biopsy forceps versus large-capacity forceps with and without needle This matters because some conditions, particularly those involving deeper layers of the gut wall, need specimens that reach beyond the surface lining.
A separate study of two different jumbo forceps designs used in inflammatory bowel disease surveillance found that the average specimen diameter was roughly 4.5 mm for both, with a measured depth around 0.55 to 0.66 mm. One design achieved slightly greater measured depth, but when pathologists evaluated how deep the tissue actually extended histologically, the difference disappeared.6PubMed Central. Novel Jumbo Biopsy Forceps for Surveillance of Inflammatory Bowel Disease: A Comparative Retrospective Assessment The takeaway for the reader is that specimen size depends on the forceps chosen, and endoscopists pick their tools based on the clinical question being asked.
Cold Forceps Versus Cold Snare for Removing Small Polyps
Cold forceps biopsy pulls double duty. Beyond simply sampling tissue for diagnosis, it has long been used to remove very small polyps, typically those under 5 mm. But cold snare polypectomy, where a thin wire loop is placed around the polyp base and cinched shut without electrocautery, has emerged as a competitor for this role. The question of which tool is better for complete removal of tiny polyps has attracted considerable research attention.
A meta-analysis pooling nine randomized trials found that cold snare polypectomy achieved a significantly higher rate of complete resection across all diminutive polyps. However, when the analysis was limited to studies using jumbo or large-capacity forceps specifically, the difference between the two methods was no longer statistically significant.7Gastrointestinal Endoscopy. Cold snare versus cold forceps polypectomy for endoscopic resection of diminutive polyps: meta-analysis of randomized controlled trials For polyps 3 mm and smaller, there was also no meaningful difference. This suggests that when endoscopists use larger forceps, cold biopsy is competitive with cold snare for the smallest growths.
A multicenter randomized trial reinforced this nuance from a different angle. The cold snare group had a dramatically higher rate of removing the polyp in one piece (about 92% versus 43% for cold forceps), which is expected since the snare encircles the entire polyp while forceps nibble at it. Despite that, the histological complete resection rate, meaning no residual abnormal tissue left behind, was comparable between the two groups (roughly 93% for cold snare versus 90% for cold forceps).8Clinics and Research in Hepatology and Gastroenterology. Comparison of cold biopsy forceps vs cold snare for diminutive colorectal polyp removal: A multicenter non-inferiority randomized controlled trial For the very smallest polyps under 4 mm, results were essentially identical. So while cold snare is increasingly preferred for polyps approaching 5 mm, cold forceps remain a reasonable option for the tiniest ones.
Bleeding Risk and Safety on Blood Thinners
One of the practical advantages of cold forceps biopsy is its favorable safety profile, particularly regarding bleeding. The small wound left behind is shallow and tends to stop bleeding on its own. This matters especially for patients taking anticoagulants or antiplatelet drugs, since these medications increase bleeding risk with any procedure.
A large Japanese prospective study involving over 3,800 biopsies found that bleeding after biopsy occurred in only about 0.15% of cases. Continuing antithrombotic medications did not significantly increase that risk.9PubMed. Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan This is reassuring for patients who cannot easily stop their blood thinners because of heart conditions or prior strokes.
A study looking at patients on antithrombotic therapy found that among those undergoing upper endoscopy with biopsy, immediate bleeding occurred in about 6% but no delayed bleeding was recorded. In colonoscopy patients on the same medications, cold snare polypectomy carried a higher rate of immediate bleeding (14%) compared to biopsy (4%), though delayed bleeding after cold snare was only about 1.3%.10PubMed. Risk of Gastrointestinal Endoscopic Procedure-Related Bleeding in Patients With or Without Continued Antithrombotic Therapy This comparison highlights one reason cold forceps biopsy remains useful: for straightforward tissue sampling, the bleeding risk is lower than more aggressive removal techniques, and most guidelines consider it safe enough to perform without stopping blood-thinning medications.
Beyond the Gut: Cold Forceps in the Lungs
Cold forceps biopsy is not limited to the gastrointestinal tract. Pulmonologists use a similar concept, called transbronchial forceps biopsy, to sample lung tissue through a bronchoscope. The forceps are smaller and the anatomy is different, but the principle is the same: a small grasping instrument pinches off tissue without heat.
In recent years, transbronchial cryobiopsy, which uses a freezing probe instead of forceps, has challenged the conventional approach in the lung. A comparison between cryobiopsy and standard forceps biopsy in lung transplant recipients found that cryo-specimens were about five times larger on average. While the rates of diagnosing acute rejection were similar between the two methods, cryobiopsy captured small airways (bronchioles) in 51% of samples versus only 8% for forceps, a significant advantage for detecting certain types of rejection.11The Journal of Heart and Lung Transplantation. Comparison of transbronchial cryobiopsy and conventional forceps biopsy in lung transplant recipients
A large randomized trial further confirmed this trend. Cryobiopsy achieved a diagnostic yield of about 89% compared to 79% for forceps across a range of lung conditions. The advantage was clearest in patients with lung nodules or masses and in transplant recipients, though for diffuse parenchymal lung disease the two techniques performed similarly.12JAMA. Cryobiopsy vs Forceps for Bronchoscopic Lung Biopsy: The FROSTBITE-2 Randomized Clinical Trial Conventional forceps biopsy remains widely available and less resource-intensive, so it has not disappeared from pulmonary practice, but cryobiopsy is gradually becoming the preferred method when larger specimens are needed.
What Happens to the Specimen After It Leaves Your Body
A biopsy is only as useful as the histology slide it eventually produces, and the steps between collection and microscope matter more than most patients realize. After the forceps extracts the sample, it is typically placed into formalin, a fixative that preserves the tissue’s cellular structure. From there, it goes to the pathology lab for processing, embedding, slicing, and staining.
One often-overlooked factor is how the specimen is oriented when it is placed for processing. A study examining serrated polyps, a type of colon polyp that can be tricky to diagnose, found that a simple tissue-handling technique performed right in the endoscopy suite substantially improved diagnostic accuracy. When specimens were carefully oriented before fixation, serrated polyps were correctly identified in about 76% of cases, compared to only 42% with conventional handling. Pathologists also agreed with each other more often when the tissue was properly prepared.13Endoscopy. A simple tissue-handling technique performed in the endoscopy suite improves histologic section quality and diagnostic accuracy for serrated polyps This is a reminder that the quality of a cold forceps biopsy does not depend solely on the instrument or the endoscopist’s skill; what happens to the tissue immediately afterward is just as important.
Molecular Testing on Small Biopsy Samples
Modern pathology often goes beyond just looking at cells under a microscope. Oncologists increasingly need molecular and immunohistochemistry testing on biopsy samples to guide treatment decisions, particularly for cancers. A natural concern is whether the small fragments from a forceps biopsy provide enough tissue for these advanced tests.
A study comparing forceps biopsy and cryobiopsy specimens from non-small cell lung cancers assessed concordance for several molecular markers. The agreement between the two specimen types for PD-L1, a protein that helps determine whether immunotherapy is appropriate, was about 85%. For HER2 and HER3, concordance was somewhat lower, in the 70-75% range.14Translational Lung Cancer Research. Concordance between cryobiopsy and forceps biopsy specimens in assessment of immunohistochemistry staining for non-small cell lung carcinoma These numbers indicate that forceps biopsy specimens can support molecular testing, though the smaller sample size introduces some loss of agreement compared to larger specimens. When precise molecular profiling is critical and a larger biopsy is feasible, clinicians may prefer techniques that yield more tissue.
Disposable Versus Reusable Forceps
Biopsy forceps come in both reusable and disposable versions, and the shift toward single-use instruments has been one of the quieter but important changes in endoscopy practice. The concern driving this shift is infection control. Because of the tightly wound, spring-like construction of a biopsy forceps, the internal lumen inevitably becomes contaminated with patient debris, and thorough cleaning and sterilization of those internal areas is extremely difficult.15Gastrointestinal Endoscopy. A performance, safety and cost comparison of reusable and disposable endoscopic biopsy forceps: a prospective, randomized trial
Studies using scanning electron microscopy have found remnant tissue material and surface scratches on reusable forceps that had been used more than 20 times, and bacteria such as E. coli have been isolated from instruments after sterilization. Guidelines for endoscopy disinfection recommend steam sterilization of reusable components when possible, but particularly in smaller healthcare settings where rigorous sterilization is more challenging, disposable forceps have clear advantages.16Clinical Endoscopy. Performance and Cost of Disposable Biopsy Forceps in Upper Gastrointestinal Endoscopy: Comparison with Reusable Biopsy Forceps
Performance also changes over time with reusable instruments. When disposable forceps were rated by endoscopists, 97% received an “excellent” performance rating, compared to only 36% for reusable forceps. The reusable instruments showed declining performance with increasing number of uses.16Clinical Endoscopy. Performance and Cost of Disposable Biopsy Forceps in Upper Gastrointestinal Endoscopy: Comparison with Reusable Biopsy Forceps Though single-use forceps carry a per-unit cost, they eliminate the reprocessing labor and equipment costs associated with reusables, and many institutions have concluded that the trade-off favors disposable instruments.
The Economics of Removing Tiny Polyps
Cost matters in healthcare, and the choice between cold forceps and cold snare for small polyp removal has a financial dimension. A prospective cohort study using real institutional pricing found that although the snare device itself cost twice as much as the forceps ($6 versus $3), the cold snare procedure took less time, which translated to lower labor costs. The total direct cost per polyp was lower for cold snare (about $18 versus $22), saving roughly $4 per polyp removed. The cost per successfully and completely resected polyp favored cold snare even more, at about $19 versus $24.17PubMed Central. Cost-Minimization and Procedural Outcomes of Cold Snare Versus Cold Forceps Polypectomy for Small Colorectal Polyps: A Prospective Cohort Study Using Real Institutional Pricing A few dollars per polyp sounds modest, but multiplied across the millions of polypectomies performed annually, these differences add up. That said, the economic picture is only one factor. In settings where polyps are very small or where a snare is not readily deployed, cold forceps remain a practical fallback.
Optical Biopsy and the Future of Tissue Sampling
An emerging technology that could eventually reduce the need for physical biopsies altogether is confocal laser endomicroscopy. This technique projects a tiny laser through the endoscope and captures microscopic images of tissue in real time, allowing the endoscopist to assess cellular architecture without removing anything. It has been described as an “optical biopsy” because it provides histology-like information during the procedure itself.18PubMed Central. Confocal endomicroscopy: instrumentation and medical applications
The practical appeal is obvious. If an endoscopist can see at the cellular level during the procedure, they can make smarter decisions about where to biopsy or whether a biopsy is needed at all. Proponents suggest it could reduce the number of unnecessary biopsies while improving the diagnostic yield of the ones that are taken, by guiding the forceps to the most suspicious-looking areas. Early research in gastric cancer and precancerous conditions supports this idea, positioning confocal endomicroscopy as a complement to traditional biopsy rather than a replacement.19Frontiers in Oncology. The benefits of using confocal laser endomicroscopy in the diagnosis of gastric cancer and precancerous lesions: a case report For now, the technology is expensive, not universally available, and still being validated against conventional histology. Cold forceps biopsy remains the standard approach when tissue needs to be physically examined under a microscope, which is most of the time.