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Delayed overt gastrointestinal bleeding after cold endoscopic biopsy
19 December 2012 (online)
We read with interest the study by Repici et al.  on the safety of cold polypectomy and biopsy. We hereby report on five patients who experienced overt gastrointestinal bleeding 24 – 48 hours after cold mucosal biopsy, four of whom required repeat endoscopy.
Between January 2006 and December 2010 (inclusive), 7275 patients underwent endoscopy with biopsy at our center. Five patients experienced overt gastrointestinal bleeding following cold mucosal biopsy (0.07 %). All five patients experienced a significant drop in hemoglobin, four required short-term hospitalization, but none required blood transfusion. Four out of the five patients had underlying conditions or were taking medications that could potentially increase the risk of bleeding. One patient was on paroxetine (a selective serotonin reuptake inhibitor), two were on amlodipine (which may inhibit platelet aggregation or induce thrombocytopenia), one was on combination anti-platelet therapy, and one had carcinoid cell infiltration on pathology, which might have contributed to bleeding through neovascularization.
Retrospective studies have suggested that the risk of overt bleeding from cold mucosal biopsy ranges from 0.02 % to 0.1 %  . Such overt bleeding commonly requires repeat endoscopy with endotherapy (as was the case in three of our patients). Some of the reported patients were taking antiplatelet therapy and others had mucosal inflammatory conditions such as Crohn’s disease or ulcerative colitis    . Reported immediate minor bleeds that are usually dealt with on the spot during the initial endoscopy are more common, ranging from 1.1 % to 2.4 %   . A study by Domellof et al. described a higher incidence of both immediate and delayed bleeding (0.8 %) following multiple cold biopsies (8 – 15 biopsies) of the anastomotic site in Billroth I and Billroth II patients .
We agree with Repici et al. that delayed bleeding following cold biopsy is very rare making this technique highly safe. We believe, however, that patient-related factors that could increase the risk of bleeding following mucosal biopsy, such as the presence of inflammatory or vascular lesions, specific drug intake, and perhaps biopsy technique (e. g. large particle or “tunnel” biopsies), need to be considered.
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