The triumph of fingers: mechanical hemostasis for postpolypectomy bleeding using the fingers

A 67-year-old woman complaining of intermittent lower abdominal discomfort and hematochezia was referred to our endoscopy center. Colonoscopy revealed a 3 × 3-cm sessile polyp located in the sigmoid colon (about 15 cm from the anal verge) ([Fig. 1]). The polyp was hidden behind colonic folds and was difficult to access with a colonoscope. After submucosal injection, the polyp was snared using electrocautery (endocut mode) in a piecemeal fashion ([Fig. 2]).

Fig. 1 A 3 × 3-cm sessile polyp located in the sigmoid colon about 15 cm from the anal verge.

Fig. 2 After submucosal injection, the polyp was snared in a piecemeal fashion.

Significant arterial bleeding occurred immediately after polyp removal, and instant repeated coagulation by thermocautery forceps was not effective ([Fig. 3]). Subsequent application of hemoclips in an attempt to stop the bleeding also failed because endoscopic vision was largely blurred by excessive blood (about 800 mL) and the source of bleeding was in a difficult position. Finally, as a last attempt before surgery was indicated, two fingers were inserted into the anus, the rectum and sigmoid colon were pulled downward gently, and pressure was applied for 10 minutes to the bleeding point, which was accurately localized by the hemoclips. The colonoscope was then advanced and retroflexed, and revealed that the bleeding had stopped. Blood scabs and fibrins were observed on the hemoclips after the fingers had been withdrawn ([Fig. 4]). No delayed bleeding occurred. When all advanced endoscopic devices for hemostasis failed, our fingers excelled and saved the patient from surgery.

Fig. 3 Significant, uncontrolled arterial bleeding occurred immediately after polyp removal.

Fig. 4 Retroflexed view of two fingers pressing against the bleeding spot; when the fingers were removed, the bleeding had stopped.

Significant intraoperative bleeding can be a major disaster for endoscopists during colonic polyp snaring or endoscopic mucosal resection, especially when the target lesion is in an awkward location making it difficult for endoscopic hemostatic methods to be used effectively [1]. In this case, the simplest, seemingly primitive, method turned out to be the most effective one. From a practical perspective, our fingers can access the sigmoid colon as far as 20 cm from the anal verge, and this simple method is an option for all endoscopists in similar emergencies.

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Competing interests: None

• Reference

• 1 Fyock CJ, Draganov PV. Colonoscopic polypectomy and associated techniques. World J Gastroenterol 2010; 16: 3630-3637