Colonoscopic Polypectomy in Glanzmannʼs Thrombasthenia

Abstract

Purpose: Glanzmann's thrombasthenia (GT) is a rare autosomal recessive bleeding syndrome characterized by absent platelet aggregation secondary to abnormal Glycoprotein IIb/IIIa complex. We report the first case of endoscopic management of large polyps in a patient with GT. Methods: A 52-year-old African American female with GT underwent four sequential colonoscopies over 9 months as enumerated below. Results: Colonoscopy 1: Performed for heme-positive stools, no blood products given. It revealed multiple sessile polyps, the 2 largest (13 and 14 mm) in the right colon. The 13 mm one was removed using saline-assisted technique in combination with Endoloop and standard cautery. Immediate post-polypectomy bleeding was observed and successfully controlled with placement of 2 Triclips. Further polypectomies were deferred. The polyp was a sessile serrated adenoma. A surgical opinion recommended endoscopic surveillance. Colonoscopy 2: Preprocedure platelets and aminocaproic acid were given. Hot biopsy polypectomies were done to remove ten smaller 4–5 mm polyps in left colon. The 14 mm polyp was left in place to help localize potential post-polypectomy bleeding. No immediate or delayed bleeding occurred. Colonoscopy 3: Preprocedure platelets and aminocaproic acid were given. The remaining 14 mm polyp was removed by saline-assisted technique. A single Quick Clip placed at the polypectomy site. Two other smaller polyps (7 and 9 mm) were also removed from the left colon using standard electrocautery, with no clips applied. Three days later patient was admitted with delayed post-polypectomy bleeding. Colonoscopy 4: Hematochezia persisted despite daily replacement of red blood cells, platelets, recombinant factor VIIa, and prothrombin concentrate complex over a period of 10 days prompted the fourth colonoscopy. Active bleeding was identified in the right colon at the 14 mm polypectomy site. Dual therapy with epinephrine injection and placement of 4 Resolution clips achieved hemostasis. No further episodes of colonic bleeding have been reported to date. Conclusion: Polypectomy in GT patients is complicated by immediate and delayed bleeding. The single previous GT case report suggested a protective effect of platelet transfusion and aminocaproic acid, to retard fibrinolysis, in preventing post-polypectomy bleeding. However, we conclude that for polyps 10 mm or larger the addition of mechanical therapy, with multiple clips, after standard cautery polypectomy, is more effective in preventing immediate and delayed post-polypectomy bleeding in patients with GT. The cost of preemptive multiple clips at the post-polypectomy site may be offset by a reduction in the need for blood products and by averting or shortening potential hospitalizations.