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DOI: 10.1055/s-0032-1325866
Delayed overt gastrointestinal bleeding after cold endoscopic biopsy
Publication History
Publication Date:
19 December 2012 (online)
We read with interest the study by Repici et al. [1] on the safety of cold polypectomy and biopsy. We hereby report on five patients who experienced overt gastrointestinal bleeding 24 – 48 hours after cold mucosal biopsy, four of whom required repeat endoscopy.
Between January 2006 and December 2010 (inclusive), 7275 patients underwent endoscopy with biopsy at our center. Five patients experienced overt gastrointestinal bleeding following cold mucosal biopsy (0.07 %). All five patients experienced a significant drop in hemoglobin, four required short-term hospitalization, but none required blood transfusion. Four out of the five patients had underlying conditions or were taking medications that could potentially increase the risk of bleeding. One patient was on paroxetine (a selective serotonin reuptake inhibitor), two were on amlodipine (which may inhibit platelet aggregation or induce thrombocytopenia), one was on combination anti-platelet therapy, and one had carcinoid cell infiltration on pathology, which might have contributed to bleeding through neovascularization.
Retrospective studies have suggested that the risk of overt bleeding from cold mucosal biopsy ranges from 0.02 % to 0.1 % [2] [3]. Such overt bleeding commonly requires repeat endoscopy with endotherapy (as was the case in three of our patients). Some of the reported patients were taking antiplatelet therapy and others had mucosal inflammatory conditions such as Crohn’s disease or ulcerative colitis [1] [3] [4] [5]. Reported immediate minor bleeds that are usually dealt with on the spot during the initial endoscopy are more common, ranging from 1.1 % to 2.4 % [1] [4] [6]. A study by Domellof et al. described a higher incidence of both immediate and delayed bleeding (0.8 %) following multiple cold biopsies (8 – 15 biopsies) of the anastomotic site in Billroth I and Billroth II patients [7].
We agree with Repici et al. that delayed bleeding following cold biopsy is very rare making this technique highly safe. We believe, however, that patient-related factors that could increase the risk of bleeding following mucosal biopsy, such as the presence of inflammatory or vascular lesions, specific drug intake, and perhaps biopsy technique (e. g. large particle or “tunnel” biopsies), need to be considered.
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References
- 1 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
- 2 Parra-Blanco A, Kaminaga N, Kojima T et al. Hemoclipping for postpolypectomy and postbiopsy colonic bleeding. Gastrointest Endosc 2000; 51: 37-41
- 3 Yousfi M, Gostout CJ, Baron TH et al. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol 2004; 99: 1785-1789
- 4 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
- 5 Rogers BH, Silis SE, Nebel OT et al. Complications of flexible fiberoptic colonoscopy and polypectomy. Gastrointest Endosc 1975; 22: 73-77
- 6 Yao MD, von Rosenvinge EC, Groden C et al. Multiple endoscopic biopsies in research subjects: safety results from National Institute of Health series. Gastrointest Endosc 2009; 69: 906-910
- 7 Domellof L, Enander LK, Nilsson F. Bleeding as a complication to endoscopic biopsies from the gastric remnant after ulcer surgery. Scand J Gastroenterol 1983; 18: 951-954