1915 Delayed Post-Polypectomy Bleeding Case Report, Using Cold Snare Technique

Abstract

INTRODUCTION: Most cases of colorectal cancer develop from colorectal polyps, therefore their early detection and removal decreases the risk of colorectal cancer death. Hot snare is the most commonly used endoscopic technique to eradicate colonic polyps with some inevitable post polypectomy bleeding. Cold snare polypectomy has been used recently because of its low risk of immediate and delayed post polypectomy bleeding. CASE DESCRIPTION/METHODS: A 66 y/o female with a history of ascending colon cancer status post right hemicolectomy presented for routine screening colonoscopy. She has a history of coronary artery disease status post stenting, systolic congestive heart failure and mechanical aortic valve for which she is on warfarin for anticoagulation. Warfarin was stopped 7 days before the procedure, without bridging. Colonoscopy showed two small polyps in the descending and sigmoid colon, and these were removed using cold snare. She was stable after colonoscopy and was discharged. Warfarin was restarted on the next day. Five days later she presented to the hospital complaining of bright red bleeding per rectum and bright red blood with stool. Hemoglobin had decreased from 11.4 (gm/dl) on the day of admission to 9.8 (gm/dl) the next day. Repeat colonoscopy was performed and a large clot was seen in the descending colon at one polypectomy site. There was no active bleeding from the clot though there was some minimal oozing with manipulation. The clot was not removed due to concerns of a large defect underneath that might bleed again. The surgery team was consulted during the procedure. Both GI and surgery teams decided not to proceed with any intervention. Another small non-bleeding ulcer in the sigmoid colon measuring 5 mm was seen and likely represent the site of previous polypectomy. She was monitored after the procedure, her symptoms and hemoglobin improved. Warfarin was restarted and discharged in stable condition. DISCUSSION: Cold snare polypectomy is being increasingly used as it is safe and efficient for small polyp removal. Newer polypectomy snares designed for cold snare polypectomy have been developed. This equipment may further decrease complications from smaller polypectomies. We present a case of rare delayed post polypectomy bleeding with the development of a large post polypectomy ulcer, even though anticoagulation was interrupted 7 days before the procedure. We used the traditional polypectomy snare. Results could have been different if the more modern cold snare polypectomy equipment used.