Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions

Background and study aims: Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist.

Patients and methods: Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission.

Results: EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size (P = 0.2), multiple excisions rather than en bloc resection (P = 0.1), polyp morphology (P = 0.2), and previous attempts (P = 0.5), were not associated with increased risk.

Conclusions: Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk – specific consensus guidelines in this area are required for colonic EMR.

References

• 1 Swan M P, Bourke M J, Alexander S et al. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service.  Gastrointest Endosc. 2009;  70 1128-1136
• 2 Kim H S, Kim T I, Kim W H et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study.  Am J Gastroenterol. 2006;  101 1333-1341
• 3 Hui A J, Wong R MY, Ching J YL et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases.  Gastrointest Endosc. 2004;  59 44-48
• 4 Moss A, Bourke M J, Williams S J et al. The Australian Multicentre colonic endoscopic mucosal resection database (AMCEMRD) – predictors of submucosal invasive adenocarcinoma and outcomes for EMR of large laterally spreading tumours (LSTs).  Gastroenterology. 2011;  (in press)
• 5 Eisen G, Baron T H, Dominitz J A et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.  Gastrointest Endosc. 2002;  55 775-779
• 6 Alexander S, Bourke M J, Williams S J et al. EMR of large sporadic non-ampullary duodenal adenomas: technical aspects and long term out-come.  Gastrointest Endosc. 2009;  69 66-73
• 7 Sorbi D, Norton I, Conio M et al. Postpolypectomy lower GI bleeding: descriptive analysis.  Gastrointest Endosc. 2000;  51 690-696
• 8 Church J. Experience in the endoscopic management of large colonic polyps.  ANZ J Surg. 2003;  73 988-995
• 9 Rosen L, Bub D S, Reed 3rd J F. Hemorrhage following colonoscopic polypectomy.  Dis Colon Rectum. 1993;  36 1126-1131
• 10 Rex D K, Lewis B S, Waye J D. Colonoscopy and endoscopic therapy for delayed post-polypectomy haemorrhage.  Gastrointest Endosc. 1992;  38 127-129
• 11 Gibbs D H, Opelka F G, Beck D E et al. Postpolypectomy colonic hemorrhage.  Dis Colon Rectum. 1996;  39 806-810
• 12 Smith L E. Fibreoptic colonoscopy, complications of colonoscopy and polypectomy.  Dis Colon Rectum. 1976;  19 407-412
• 13 Shiffman M L, Farrel M T, Yee Y S et al. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDs.  Gastrointest Endosc. 1994;  40 458-462
• 14 Waye J D, Kahn O, Auerbach M E et al. Complications of colonoscopy and flexible sigmoidoscopy.  Gastrointest Endosc Clin N Am. 1996;  6 : 2 343-377
• 15 Hopper A, Bourke M J, Williams S J, Swan M P. Giant laterally spreading tumours of the papilla: endoscopic features, resection technique and outcome.  Gastrointest Endosc. 2010;  71 967-975
• 16 Bourke M J. Current status of colonic endoscopic mucosal resection in the west and the interface with endoscopic submucosal dissection.  Dig Endosc. 2009;  21 S27-S32
• 17 Yousfi M, Gostout C J, Baron T H et al. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin.  Am J Gastroenterol. 2004;  99 1785-789
• 18 Nakajima H, Takami H, Sasaki Y et al. Risk of abnormal bleeding after endoscopic biopsy and polypectomy in patients with aspirin use (abstract).  Gastrointest Endosc. 1994;  41 328
• 19 DiPrima R E, Barkin J S, Blinder M et al. Age as a risk factor in colonoscopy: fact versus fiction.  Am J Gastroenterol. 1998;  83 123-125
• 20 Sawhney M S, Salfiti N, Nelson D B et al. Risk factors for severe delayed postpolypectomy bleeding.  Endoscopy. 2008;  40 115-119
• 21 Dyer S, Quigley E, Noel S M et al. Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy.  Gastrointest Endosc. 1991;  37 361-364