The Patient Is Not in Distress, Should We Consider PPS? A Case of Post-Polypectomy Syndrome

Abstract

CASE: A 69 year-old man presented to our hospital with chills, nausea, and a mild headache 2 hours after an uncomplicated colonoscopy with hot snare polypectomy of a 2.5 cm ascending colon polyp. He denied vomiting, abdominal pain, cough, dysuria or changes in bowel movements. He admitted to having fever and was passing flatus. On examination, his vital signs were remarkable only for a temperature of 101.4 °F. He was nontoxic appearing and had a soft abdomen that was nontender and with bowel sounds present. Labs were normal. X-rays were negative for subdiaphragmatic free air. Cultures and urinalysis were negative for infection. Gastroenterology was consulted to evaluate the patient and diagnosed him with postpolypectomy syndrome (PPS). The patient was treated with supportive care, including IV fluids, progression of diet as tolerated and ondansetron with resolution of symptoms. DISCUSSION: PPS is a rare complication of colonoscopy with polypectomy. The incidence of PPS, also referred to as postpolypectomy syndrome or transmural burn syndrome, is reported to vary from 0.003 to 0.5 % of colonoscopies. Risk factors for developing PPS include hypertension, large lesion size (>2 cm), lesions on the right side of the colon, and non-polypoidal lesions. Of note, our patient had two of the aforementioned risk factors. Patients with PPS most commonly present with generalized abdominal pain, fever, tachycardia, and leukocytosis within 12 hours of a colonoscopy. A milder form of PPS, termed postpolypectomy fever, results in a fever following colonoscopy with no evidence of other fever foci (our patient would most likely fall into this category). Treatment of PPS includes supportive care with intravenous fluids, pain control, advancing diet as tolerated by patient, and antibiotics that cover for gram- negative and anaerobic organisms. These patients typically have an excellent prognosis with only a 2.9% rate of complication and no observed mortality. Common clinical practice to prevent complications for snare cautery include closing the snare further up the base of the polyp, or tenting the polyp towards the colonic lumen before applying heat, though no single technique has proven to be most effective. Overall, more research needs to be done to determine which techniques are the safest and most effective for removing polyps.