Journal of the Canadian Association of Gastroenterology, 2018, 1(2), 51–52 doi: 10.1093/jcag/gwy015 Image of the Month Advance Access publication 1 June 2018 Image of the Month 1 1 Mah tt ew Woo MD , Robert Bechara MD Correspondence: Dr. Mah tt ew Woo, MD, Highest Academic Degree(s): MD, FRCPC, Division of Gastroenterology, Division of Gastroenterology, Department of Medicine, Queen’s Department of Medicine, 99 University Ave, Kingston, ON, University Canada K7L 3N6. Email email@example.com Key words: Colonoscopy; Endoscopy; Hemostasis. A 68-year-old male with multiple medical comorbidities, including end-stage renal peritoneal dialysis, under went screen- ing colonoscopy prior to kidney transplant. Colonoscopy demonstrated three polyps in the descending colon; a 2-mm sessile polyp was removed with cold snare; a 7-mm sessile was polyp removed with hot snare; and distal to that, a 1-cm ses- sile polyp was removed with hot snare. There were no imme- diate complications, and the patient was discharged home. He represented a week later with 24 hours of rectal bleeding and a hemoglobin drop from 101 g/L to 76 g/L. Repeat colonoscopy showed a large adherent clot that measured the width of the lumen (Figure 1). Two clips were placed at the base (Figure 2), and this was removed with hot-snare (Figure 3), demonstrat- ing a 2–3 mm vessel that was clipped (Figure 4, 5). He was dis- charged with no recurrence of bleeding. Figure 1. Large adherent clot at site of previous polypectomy (top-left). Figure 3. Clot removed with hot-snare (bottom-left). Figure 2. Clot clipped at the base (top-right). © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 51 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/51/5026670 by Ed 'DeepDyve' Gillespie user on 17 June 2018 52 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 Figure 4. Visible vessel at site of previous polypectomy (clip to scale). Figure 5. Visible vessel at site of previous polypectomy (small). Conflicts of interest Discussion The authors have no conflicts of interest to declare. Postpolypectomy bleeding (PPB) is a known complication of colonoscopic polypectomy and is reported to occur at a fre- quency of 0.3%–10.2% (1). Some factors associated with PPB References include polyp size, location in the right colon, sessile mor- phology, number of polyps removed and use of antiplatelet 1. Gimeno-García AZ, de Ganzo ZA, Sosa AJ, et al. Incidence and and anticoagulant use (2). PPB can be classified as immediate, predictors of postpolypectomy bleeding in colorectal polyps larger than 10 mm. Eur J Gastroenterol Hepatol. 2012;24(5):520. when bleeding occurs immediately aeft r polyp resection, or 2. Pigò F, Bertani H, Manno M, et al. Colonic postpolypectomy delayed, when bleeding occurs ae ft r the colonoscopy. A pro - bleeding is related to polyp size and heparin use. Clin Endosc. pensity-matched retrospective cohort study in 539 patients with 2017;50(3):287–292. doi:10.5946/ce.2016.126. colorectal polyps up to 11 mm in size demonstrated significantly 3. Yamashina T, Fukuhara M, Maruo T, et al. Cold snare polypectomy less delayed postpolypectomy bleeding with cold snare polyp- reduced delayed postpolypectomy bleeding compared with con- ectomy than hot snare polypectomy (3). Endoscopic hemosta- ventional hot polypectomy: A propensity score-matching analysis. sis with clips is safe and effective in PPB. (4 ) There is varying Endosc Int Open. 2017;5(7):E587–E594. evidence regarding the role for prophylactic endoscopic ther- 4. Lee J-M, Kim WS, Kwak MS, et al. Clinical outcome of endoscopic apy. A systematic review and network meta-analysis of 15 RCTs management in delayed postpolypectomy bleeding. Intest Res. involving 3462 patients who underwent colonoscopic polyp- 2016;15(2):221–227. ectomy (median polyp size 16 mm) demonstrated relative effi - 5. Park CH, Jung YS, Nam E, et al. Comparison of efficacy of prophy - cacy of epinephrine-saline injection (RR=0.32, 0.11–0.67) and lactic endoscopic therapies for postpolypectomy bleeding in the colorectum: A systematic review and network meta-analysis. Am J mechanical therapies (RR=0.13, 0.03–0.37) for reducing early Gastroenterol. 2016;111(9):1230–1243. PPB (<24 hours postpolypectomy), but not delayed PPB (5). Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/51/5026670 by Ed 'DeepDyve' Gillespie user on 17 June 2018
Journal of the Canadian Association of Gastroenterology – Oxford University Press
Published: Jun 1, 2018
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