Clin Endosc.  2025 Mar;58(2):191-200. 10.5946/ce.2024.241.

Post-polypectomy colorectal bleeding: current strategies and the way forward

• Nishad N
• Thoufeeq MH

• KMID: 2566138
• DOI: http://doi.org/10.5946/ce.2024.241

Abstract

Post-endoscopic mucosal resection (EMR) bleeding, or clinically significant post-EMR bleeding, is influenced by factors such as polyp size, right-sided colonic lesions, laterally spreading tumors, anticoagulant use, and comorbidities like cardiovascular or chronic renal disease. The optimal prophylactic therapy for post-EMR bleeding remains unknown, with no consensus on specific criteria for its application. Moreover, prophylactic measures, including clipping, suturing, and coagulation, have produced mixed results. Selective clipping in high-risk patients is cost-effective, whereas universal clipping is not. Studies and meta-analyses indicate that routine prophylactic clipping does not generally reduce post-polypectomy bleeding but may be beneficial in cases of large proximal lesions. Some studies have revealed that the post-polypectomy bleeding risk after EMR of transverse colonic lesions is lower than that of the ascending colon and caecum, suggesting limited efficacy of clipping in the transverse colon. Cost-effectiveness studies support selective clipping in high-risk groups, and newer static agents such as PuraStat are alternatives; however, their cost-effectiveness is undetermined. Further research is required to establish clear guidelines and refine prophylactic strategies to prevent post-EMR bleeding.

Keyword

Clipping; Colonoscopy; Post-polypectomy bleeding; PuraStat

Figure

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  Fig. 1. (A) Zipper closure involves sequentially clipping small or elongated lesions beginning from a corner and gradually pulling the wound edges together clip by clip. (B) Before zipper closure, approximate the wound edges. For larger or round lesions, position the clips on opposite sides to form an almond shape, then proceed by placing additional clips in between. Adapted from Turan et al. Expert Rev Med Devices 2019;16:493–501, according to the Creative Commons license.23

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  Fig. 2. (A) Different kinds of commonly used clips for managing post-polypectomy bleeding. (B) A wide open base is present after endoscopic mucosal resection (EMR). (C) Application of metal clips and PuraStat at completion. (D) A wide open base is present after EMR. (E) Complete closure of the EMR site using metal clips for the zipper closure. Both patients did not develop significant bleeding after the procedure.

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