Management of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a retrospective multi-center cohort study

Abstract

Background and study aims Delayed bleeding (DB) is the most frequent major adverse event after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs). Evidence-based guidelines for management of DB are lacking. We aimed to evaluate the clinical presentation, treatment and outcome of patients with DB and to determine factors associated with hemostatic therapy.

Patients and methods Patients with DB were identified by analyzing all consecutive EMR procedures for LNPCPs (≥ 2 cm) from one academic center (2012–2017) and seven regional hospitals (2015–2017). DB was defined as any postprocedural bleeding necessitating emergency department presentation, hospitalization or reintervention. Outcome of DB was assessed for three clinical scenarios: continued bleeding (CB), spontaneous resolution without recurrent bleeding during 24 hours observation (SR), and recurrent bleeding (RB). Variables associated with hemostatic therapy were analyzed using logistic regression.

Results DB occurred after 42/542 (7.7 %) EMR procedures and re-colonoscopy was performed in 30 patients (72 %). Re-colonoscopy and hemostatic therapy rates were 92 % and 75 % for CB (n = 24), 25 % and 8 % for SR (n = 12), and 83 % and 67 % for RB (n = 6), respectively. Frequent hematochezia (≥ hourly) was the only factor significantly associated with hemostatic therapy (RR 2.23, p = 0.01). Re-bleeding after endoscopic hemostatic therapy occurred in 3/22 (13.6 %) patients.

Conclusion Ongoing or recurrent hematochezia is associated with a high rate of hemostatic therapy, warranting re-colonoscopy in these patients. A conservative approach is justified when bleeding spontaneously settles, and without recurrent hematochezia during 24 hours observation patients can be safely discharged without endoscopic re-examination.

Publication History

Received: 22 January 2020

Accepted: 18 May 2020

Article published online:
21 July 2020

• References

• 1 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 2 Moss A, Bourke MJ, Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1908-1918
• 3 Law R, Das A, Gregory D. et al. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: An economic analysis. Gastrointest Endosc 2016; 83: 1248-1257
• 4 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: A systematic review and meta-analysis. Gut 2016; 65: 806-820
• 5 Burgess NG, Metz AJ, Williams SJ. et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 651-661.e3
• 6 Albéniz E, Fraile M, Ibáñez B. et al. A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions. Clin Gastroenterol Hepatol 2016; 14: 1140-1147
• 7 Bahin FF, Rasouli KN, Byth K. et al. Prediction of Clinically significant bleeding following wide-field endoscopic resection of large sessile and laterally spreading colorectal lesions: a clinical risk score. Am J Gastroenterol 2016; 111: 1115-1122
• 8 Metz AJ, Bourke MJ, Moss A. et al. Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy 2011; 43: 506-511
• 9 Burgess NG, Williams SJ, Hourigan LF. et al. A management algorithm based on delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 1525-1533
• 10 Sawhney MS, Salfiti N, Nelson DB. et al. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 2008; 40: 115-119
• 11 Backes Y, Schwartz MP, Ter Borg F. et al. Multicentre prospective evaluation of real-time optical diagnosis of T1 colorectal cancer in large non-pedunculated colorectal polyps using narrow band imaging (the OPTICAL study). Gut 2019; 68: 271-279
• 12 Hwang JH, Konda V, Abu Dayyeh BK. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 13 Carson JL, Triulzi DJ, Ness PM. Indications for and Adverse Effects of Red-Cell Transfusion. N Engl J Med 2017; 377: 1261-1272
• 14 Dutch federation of Intensive Care (NVIC). Richtlijn Bloedtransfusie. CBO; 2011 Available from (Accessed Dec 2018): https://nvic.nl/sites/nvic.nl/files/CBO%20Richtlijn%20Bloedtransfusie.pdf
• 15 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157: 977-984.e3
• 16 Albeniz E, Alvarez MA, Espinos JC. et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019; 157: 1213-1221.e4
• 17 Oakland K, Jairath V, Uberoi R. et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol 2017; 2: 635-643
• 18 Niikura R, Yasunaga H, Yamada A. et al. Factors predicting adverse events associated with therapeutic colonoscopy for colorectal neoplasia: a retrospective nationwide study in Japan. Gastrointest Endosc 2016; 84: 971-982.e6
• 19 Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397