Introduction
Delayed post-polypectomy hemorrhage (DPPH) is caused by a submucosal artery in the ulcer base after polypectomy. Doppler endoscopic probe (DEP) is highly effective in detecting blood flow in medium or large sized arteries in PP induced ulcers (PPIUs). With focal treatment & arterial blood flow obliteration, DEP guided treatment has been reported to prevent severe DPPH throughout the colon (Ref). In contrast, mixed success rates with hemoclip (HC) closure are reported. The HC technique can achieve single-layer mucosal closure but buries submucosal arteries often without obliterating blood flow. It has been reported not to be cost effective, nor efficacious in the left colon or rectum. New treatments are needed to prevent DPPH - a common complication of polypectomy.
Aims & Methods
AIMS: To report final results of a randomized controlled trial (RCT) of blood flow monitoring & focal treatment to prevent DPPH.
METHODS: This was a multicenter RCT of high-risk outpatients having colonoscopies & prospective follow-up (FU). Polyps were removed by EMR &/or thermal coagulation. Patients were stratified by chronic anti-platelet or anti-thrombotic drug use & a PPIU of 10-40 mm; or for those without bleed drugs, PPIU’s were 15-40 mm. After polypectomy, randomization was to either standard management (e.g. following GI guidelines for bleed drugs) or DEP interrogation of PPIU’s & guided treatment with HCs in the PPIU until arterial blood flow was eradicated (1). Patients & their caregivers were blinded to treatments. Prospective FU was by a research coordinator at 7, 14, & 30 days to record complications (e.g. abdominal pain, vomiting, fever or dizziness); rectal bleeding & its severity (e.g. # bloody BM’s/day & # of days bleeding); & whether patients sought ER, clinic, or telemedicine care or hospitalization for bleeding. Major DPPH was diagnosed in patients with severe bleeding for 5 or more days &/or who needed hospitalization. Lesser bleeds were < 4 days, but without hospitalization. Demographic, laboratory, colonoscopic, & pathology results & 30 day outcomes were prospectively recorded on standard forms. Coded data were entered into HIPAA compliant computer files & managed with SAS. This is the final analysis by a biostatistician.
Results
For 180 high risk patients, 92 had standard treatment & 88 had DEP guided treatment. DEP monitoring & focal treatment was quick & easy. Treatment groups were well matched at baseline, including mean age of 68 years, 76% males; 55% on aspirin, 21 % on an anti-coagulant, & 9% on another anti-coagulant. Mean polyp size was 16 mm, most were sessile, & 57% were right colon. There were no drop-outs, severe adverse events, or deaths. However, DEP patients had significantly lower rates of DPPU bleeding – both major & total- as in Table 1.
Table 1. Delayed Post Polypectomy Induced Ulcer Bleeds by Treatment Group
| DELAYED BLEEDS | Standard (N = 92) | Doppler (N = 88) | Risk Difference | SE | 95% CI’s* | NNT** | ****P-Value |
| Total Delayed PPIU Bleeds | 11 (11.96 %) | 2 (2.27 %) |
9.68% |
3.7% |
2.36%;17.0% |
10.3 |
0. 0127 |
| Major Delayed Bleeds | ***8 (8.7 %) | 1 (1.14 %) | 7.56 % | 3.1% | 1.39%;13.7% | 13.2 | 0.0204 |
| Lesser Delayed Bleeds | 3 (3.26 %) | 1 (1.14 %) | 2.12% | 2.2% | -2,13%;6.4% | 47.1 | 0.5473 |
Legend: Treatment results shown as N’s & (%). * 95% CI’s is Confidence Intervals. **NNT is the number needed to treat. *** All were hospitalized except 1 patient with severe bleeding who refused hospitalization during the COVID pandemic. ****P values performed with Fisher exact test
Conclusion
DEP monitoring of arterial blood flow & guided focal treatment resulted in significantly lower rates of severe & total DPPHs than standard medical treatment. This is an easy, safe, & anatomically based method to prevent DPPH throughout the colon and rectum.
References
Jensen DM, Gornbein J, Fejleh P et al. Prediction and Prevention of Delayed Post-polypectomy-induced Ulcer Hemorrhage Based Upon an Anatomic Study and Multivariable Analyses. Dig Dis Sci 2026 Feb 10. Doi: 10.107/s10620-026-0970-2. Online ahead of print.
Disclosure
Study supported by a Veterans Administration Merit Review Grant - 5I01CX001403. Dr. Jensen has received research funding from Vascular Technology Inc.