Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions

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1 Showa Univ J Med Sci 12(3), , September 2000 Original Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions Masaaki MATSUKAWA, Mototsugu FUJIMORI, Takahiko KOUDA, Takeshl YAMASAKI, Kenya TADOKORO, Atsushl SATOH, Masatoshl NAKAMACHI, Shinichirou OKABE, Ken SHIMADA, Wataru YAMAMOTO and Minoru KURIHARA Abstract: Thirty bleeding cases after therapeutic endoscopy for 2916 colorectal lesions were analyzed. The therapeutic endoscopy method, size of lesions, anatomic location, latency between endoscopic therapy and rectal bleeding were recorded for each case. The bleeding rate by hot biopsy was 0.4% (5 lesions), by polypectomy 1.4% (20 lesions) and by endoscopic mucosal resection 1.7% (5 lesions). The bleeding rate was associated with the size of the colorectal polyp. Sessile lesions on the cecum and ascending colon had the highest incidence of bleeding after therapeutic endoscopy. Pedunculated lesions bled more than any other lesions in the rectosigmoid region. A 93% bleeding rate was recognized within the ninth day after therapeutic endoscopy. Endoscopic clipping was the most effective for bleeding after endoscopic resection. None of our cases underwent surgical operation for bleeding after endoscopic resection. Based on these results, we would perform endoscopic clipping to prevent bleeding after removal of any lesion more than 1.0cm in size, such as a sessile lesion on the cecum and ascending colon, or a pedunculated lesion on the rectosigmoid region. Key words: colorectal lesion, endoscopic resection, polypectomy, bleeding Introduction The overall prevalence rate of colorectal neoplasm is increasing in Japan due to the westernization of diet. According to official health and welfare statistics1), there were 32,630 deaths from colorectal cancer in This is a more than a 6-fold increase from the 5037 deaths in For early detection of colorectal cancer there is a mass survey by immunological fecal occult reaction in Japan. A patient of positive reaction in the fecal occult reaction is performed a scrutiny of the large bowel by barium enema or colonoscopy, which has led to the discovery of many colorectal neoplasms. A lot of those detected neoplasms have been removed by endoscopic resection, however it is important to not remove a lesion with findings of invasive cancer. Colorectal neoplasms may be removed by endoscopy, by hot biopsy for a minute lesion, by polypectomy for a pedunculated/sessile lesion or by endoscopic mucosal resection (EMR) for a plaque-like / depressed lesion. Complications occur more frequently after polypectomy, with a 2 % incidence of hemorrhage, and a 0.3% incidence of perforation. This complication rate for a therapeutic Department of Gastroenterology, Toyosu Hospital, Showa University, Toyosu, Koto-ku, Tokyo , Japan.

2 Masaaki MATSUKAWA, et al procedure is not insignificant but satisfactory in view of the greater morbidity and mortality of abdominal surgery that it frequently replaces. In the present study we determined the incidence of bleeding after endoscopic resection, and compared it with the size of lesions, method of endoscopic resection, and period from the resected day to bleeding day, and also determined the results of treatment of bleeding. Method We reviewed bleeding complications related to 2916 lesions in 1026 patients who underwent endoscopic resections between January 1995 and March When we performed endoscopic removal of a lesion more than 0.6 cm in size, the patient was kept in for three days. Patients with bleeding complications after therapeutic colonoscopy came to our hospital for treatment. We excluded cases that bled immediately after endoscopic therapy from this study. Therefore, we did not perform therapy after removal of the endoscopic resection unless we recognized bleeding from the resected lesion at initial colonoscopy. Therapeutic colonoscopy are by hot biopsy, polypectomy and EMR. Endoscopic treatments were performed eight doctors under the supervision of senior doctors. We used at the same level of electric current for cutting and coagulation in hot biopsy. Polypectomy and EMR (Hot biopsy). removed by polypectomy. clipping, we sprayed the ulcer with thrombin. endoscopy was analyzed by chi square test. Results The relation between bleeding after the therapeutic endoscopy and colorectal polyps in Sessile polyps less than 0.5 cm in size are most easily eradicated by hot biopsy forceps Sessile polyps more than 0.5 cm in size and pedunculated polyps were Plaque-like lesions and depressed lesions of any size were resected by EMR. The EMR method is described in detail in Deyhle et al. 2); initial local injection of saline around the lesion, which leads to secondary mucosal swelling, and finally removes it by snare-cautery technique. Hot biopsy was used for 1243 lesions, polypectomy for 1383 lesions and EMR for 290 lesions. Thirty patients had bleeding after endoscopic therapeutic procedures for colorectal lesions. The thirty patients had a mean age 57.8 years (range, 39 to 76) and included 25 men. Pathological findings of these bleeding lesions were 2 invasive cancers, 6 cancer, 18 adenomas and 4 hyperplastic polyps. We recorded the size of the lesion, method of colonoscopic resection, and therapeutic procedure for treatment of bleeding. When a patient with a complaint of rectal bleeding after endoscopic removal of a colorectal lesion visited our hospital, we looked for a bleeding focus by colonoscopy after saline enema within 24 hours. When we did not recognize blood coagulation in the ulcer after endoscopic removal of the lesion, we undertook conservative treatment (dripping transfusion or styptic) for the ulcer. But in that case of tiny blood coagulation in the ulcer, we have treated by endoscopic spraying of absolute ethanol or thrombin. And for obvious blood coagulation in the ulcer, we treated by colonoscopic therapy with clipping. In cases in which blood continued to ooze from the ulcer after Incidence of bleeding after therapeutic size is shown in Table 1. The overall incidence of bleeding after therapeutic endoscopy is

3 Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions 255 Table 1. Incidence of bleeding rate after therapeutic endoscopy by size of colorectal lesion * : p=0.006, ** : p=0.012 Table 2. Anatomic distribution of bleeding lesions after therapeutic colonoscopy and incidence of bleeding C/A : cecum and ascending colon, T : transverse colon, D : descending colon, S : sigmoid colon, R : rectum 1.0% in this study. Ninety-six percent (1197/1243) of the lesions less than 0.6 cm in size was removed by hot biopsy. Many of the sessile or subpedunculated polyps more than 0.5 cm in size were treated by polypectomy. The bleeding rate was lowest after hot biopsy of the three endoscopic treatments used. The bleeding rate after therapeutic endoscopy for lesions more than 2.1 cm in size was about 5 %, whereas the bleeding rate for the lesion less than 2.0 cm in size was only about 1 % (p< 0.002). Therefore, the bleeding rate clearly increased with increasing size of the lesion irrespective of treatment method. The relationship between therapeutic method and bleeding after the therapeutic colonoscopy is also shown in Table 1 (p< 0.012). The total incidence of bleeding after hot biopsy was significantly lower than that after polypectomy (p = 0.006) and EMR (p = 0.012). Polypectomy was associated with the highest number of bleeding cases, but the incidence of bleeding after polypectomy was not very different to that of EMR. The relationship between anatomic distribution bleeding rate to therapeutic colonoscopy is shown in Table 2. There were 19 lesions (63%) on the cecum and ascending colon in thirty bleeding lesions after therapeutic endoscopy. Endoscopic therapy for lesions of the caecum and ascending colon was significantly more bleeding rate than of the other locations

4 256 Masaaki MATSUKAWA, et a1 Table 3. Anatomic distribution, macroscopic type and size of bleeding lesion after therapeutic colonoscopy Ip : pedunculated lesion Is : sessile lesion II : plaque-like/depressed lesion C/A : cecum and ascending colon T/D : transverse and descending colon S/R: sigmoid colon and rectum Table 4. The relationship between the type of endoscopic therapy and the period of time before rectal bleeding Hot B.: Hot biopsy by chi square test. Table 3 shows sessile lesions on the cecum and ascending colon had the highest incidence of bleeding after therapeutic endoscopy. The relationship between therapy and period from therapeutic endoscopy to rectal bleeding is shown in Table 4. Bleeding after hot biopsy was recognized within five days, whereas bleeding was seen after polypectomy and EMR within the first day. We recognized 28 cases (93%) of the bleeding cases within 9 days after therapeutic colonoscopy. Therapies for bleeding after therapeutic colonoscopy were either conservative or endoscopic. Table 5 shows the therapies used for bleeding after therapeutic colonoscopy. Conservative therapy consisted of fluid transfusion and styptic for ulcer without blood coagulation. Endoscopic therapies were absolute ethanol or thrombin spray, and/or clipping. In 15 cases after therapeutic endoscopy the bleeding lesion was caught by clip and bleeding was stopped. In 4 cases of the bleeding we sprayed thrombin on the ulcer after clipping, because we recognized blood oozing from the ulcer. In 3 cases with tiny blood coagulation the ulcer was sprayed with absolute ethanol and in 4 cases with thrombin. Four cases were

5 Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions 257 Table 5. Anatomic distribution of bleeding, size of bleeding lesion and therapy for bleeding lesion T : Thrombin E : Ethanol treated by conservative therapy. A lot of the bleeding lesions on the cecum and ascending colon were treated by clipping or thrombin spray after clipping. No patients underwent surgical operation for bleeding in this study. Discussion In this study, we removed 290 plaque-like or depressed lesions by EMR. There was no significant difference in bleeding rate between after polypectomy and after EMR. Kaneko et a1.3) found a higher bleeding rate after polypectomy than after EMR. This difference in bleeding rate may be because we removed larger lesions of greater than 1 cm in size by EMR. We often performed endoscopic removal of lesions greater than 1 cm in size which doctors at other hospital could not resect. The reported incidence of bleeding after colonoscopic polypectomy ranges from 0.6%4) to 2.24%5). In this study the incidence of bleeding was relative low rate (1 %) was relatively lower. We thought this lower incidence of bleeding may reflect the fact that we performed therapeutic endoscopy on non-invasive lesions. But the bleeding rate after therapeutic endoscopy for a lesion between 1.0 and 2.1 cm was 3.2%, whereas for a lesion more than 2.0 cm 5.2%. Therefore the rate of bleeding increased with increasing size of lesion resected by endoscopy from our study. Hot biopsy was associated with the lowest bleeding rate after therapeutic endoscopy, but this is probably because most of the lesions treated by hot biopsy were less than 0.6 cm in size. Van Gossum et a1.5) reported that 10 of 14 bleeding patients after therapeutic endoscopy had lesions located in the rectosigmoid region. In eight pedunculated lesions more than 1 cm in size in our bleeding cases, six lesions were in the rectosigmoid region. But in our study, the lesion in 19 of 30 bleeding patients was located in the cecum and ascending colon. Van Gossum et al. also reported that 17% of polyps were located in the ascending colon, but we found 23% of polyps in the ascending colon. Webb et al.6) reported that anatomic location of polypectomized lesions demonstrated a shift to the right side of the colon. We cannot explain the higher rate of bleeding in the lesion of the cecum or

6 258 Masaaki MATSUKAWA, et al ascending colon than in the lesions of the other colon. The higher bleeding rate of sessile lesions may be related to blood supply or the thin colonic wall of the cecum and ascending colon. Bleeding complicated 6 lesions of 1842 hot-biopsies to remove small polyps in our study. But Macrae et al. 8) reported that no bleeding complicated any of the 1458 hot-biopsies. We have divided the latency between therapeutic endoscopy and bleeding into 2 groups (within the 3rd day and after the 3rd day). In our study 30% (nine cases) of the bleeding cases was within the third day, and 70% occurred after the third day. Conservative therapy for minor bleeding after therapeutic endoscopy was fluid transfusion. Therapies for the bleeding after therapeutic resection of the lesion include local injection of adrenaline or ethanol, heat probe, or clipping. In our experience, clipping is the most effective therapy for bleeding from ulcer, giving obvious blood coagulation. The bleeding rate after therapeutic endoscopy for colorectal lesions was 1 %, and bleeding rate for the lesion more than 2.1 cm in size was about 5 %. We described thirty patients in whom bleeding after therapeutic colonoscopy was successfully and safely treated by conservative or endoscopic therapy. Based on these results, we perform endoscopic clipping to prevent bleeding after polypectomy for a lesion of more than 1 cm in size, such as a sessile lesion on the right side colon, and a pedunculated lesion on the rectosigmoid region. References 1) Health and welfare statistics association: Statistic in cause of death in Japan. Journal of health and welfare statistics 45: (1998) (in Japanese) 2) Deyhle P, Largiader F and Jenny S: A method for endoscopic electroresection of sessile colonic polyps. Endosconv 5: (1973) 3) Kaneko E, Harada H and Kasugai T: Second reports of complications of diagnostic and therapeutic endoscopy in Japan. Results of an inquiry. Gastroenterol Endosc 38: (1995) (in Japanese) 4) Nivatvongs S: Complications in colonoscopic polypectomy. An experience with 1555 polypectomies. Dis Colon Rectum 29: (1986) 5) Fruemorgen P and Demling L: Complications of diagnostic and therapeutic colonoscopy in the Federal Republic of Germany. Results of an inquiry. Endoscopy 2: (1979) 6) Van Gossum A, Cozzoli A, Adler M, Taton G and Cremer M: Colonoscopic snare polypectomy; analysis of 1485 resections comparing two types of current. Gastrointest Endosc 38: (1992) 7) Webb WA, McDaniel Land Jones L: Experience with 1000 colonoscopic polypectomies. Ann Surg 201: (1985) 8) Macrae FA, Tan KG and Williams CB: Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 24: (1983) [Received April 21, 2000: Accepted June 27, 2000]