Reply to Sarkis et al.

We are grateful to Sarkis et al. for reporting their series of over 7000 cold biopsies during colonoscopy that showed a very low rate of delayed bleeding (i. e., 0.07 %) without the need for transfusion in any of the five cases [1]. The authors also successfully documented the presence of potential patient-related or lesion-related factors that could have caused a delayed bleeding, such as the use of antiplatelet or other drugs. The authors conclude that patient-related and lesion-related risk factors should be cautiously evaluated, before performance of cold biopsy or cold polypectomy.

The series by Sarkis et al. largely confirms the high safety level that we recently described for cold polypectomy for subcentimeter lesions [2]. In the same study, we showed that therapy with antiplatelet agents was an independent predictor of immediate post (cold) polypectomy bleeding. The lack of delayed bleeding in our series may be at least partly related to the use of endoscopic hemostasis by means of clips to treat immediate post-polypectomy bleeding [2]. On the other hand, a previous series excluded the possibility of a higher risk of bleeding following simple cold biopsies in the gastrointestinal tract when patients were being treated with antiplatelet agents [3]. Based on these findings, the use of antiplatelet drugs should not be considered as a relative contraindication for performing cold biopsy or cold polypectomy. However, we agree that such patients should be carefully monitored during and after the procedure – especially in the case of lesions > 5 mm in size or with multiple biopsies – and endoscopic hemostasis should be systematically performed in the case of immediate bleeding, to prevent delayed bleeding also.

Sarkis et al. also suggested that the potential effect of non-antiplatelet drugs on bleeding should be considered [1]. In theory, we agree that there is some epidemiological evidence that spironolactone and antidepressants may increase gastrointestinal bleeding risk, whilst conflicting data exist regarding calcium antagonists, with statins appearing to exert a protective role [4]. However, it should be noted that these drugs have been only associated with spontaneous gastrointestinal bleeding – that is, by causing erosions and/or impairing ulcer healing – whilst no study has actually demonstrated their pathogenetic role in bleeding following polypectomy/biopsy. For this reason, further evidence is needed before including such drugs among the recognized risk factors for delayed bleeding after polypectomy/biopsy.

• References

• 1 Sarkis F, Abu Daya H, Sharara A et al. Delayed overt gastrointestinal bleeding after cold endoscopic biopsy. Endoscopy 2013; 45: 73
• 2 Repici A, Hassa C, Vitetta E et al. Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012; 44: 27-31
• 3 Whitson MJ, Dikman AE, von Althann C et al. Is gastroduodenal biopsy safe in patients receiving aspirin and clopidogrel? a prospective, randomized study involving 630 biopsies. J Clin Gastroenterol 2011; 45: 228-233
• 4 Zullo A, Hassan C, Campo SM et al. Bleeding peptic ulcer in the elderly: risk factors and prevention strategies. Drugs Aging 2007; 24: 815-828