Aralık 2011

104-105

Mehmet BEKTA޹, Onur KESKİN¹, Esin KORKUT¹, Yusuf ÜSTÜN¹, Vikas GUPTA², Hatice ANIKTAR¹, Hülya ÇETİNKAYA¹, Kadir BAHAR¹, İrfan SOYKAN¹

Department of ¹Gastroenterology, Ankara University, School of Medicine, Ankara
²University of Texas, School of Public Health, Houston, Texas, USA

Alt gastrointestinal kanama şüphesiyle kolonoskopi yapılan 61 yaşında kadın hastada sigmoid kolonda uzun saplı bir polip saptandı. Polipektomi yapılan hastada işlem sonrası ciddi arteriyel kanama olması üzerine işlem bölgesine acilen epinefrin ve sklerozan ajan uygulanarak kanama kontrolü sa¤landı. 3 saat sonra hastanın rektal kanamasının tekrarlaması üzerine kontrol kolonoskopide polip sapından kanamanın devam etti¤i gözlendi. Bunun üzerine polip sapına gastroskop ile endoskopik bant ligasyon uygulandı. Bu uygulama ile kanama başarılı bir şekilde durdurulabildi.

Bant ligasyon, polipektomi, hemoraji

Endoscopic polypectomy is considered the standard of care for the treatment of colorectal polyps (1). The two most important complications of polypectomy are perforation and bleeding. Hemorrhage has been reported to occur after 1-6% of polypectomies, with clinically significant bleeding in only some 1% of the cases (1-4). In general, bleeding occurs during the transection of the polyp stalk. Delayed bleeding can occur after a few hours or even after a few days in 2% of the patients. Less than 50% occurs immediately after the procedure (1-3).

Bleeding prophylaxis can be attempted using several techniques, such as application of hemoclips, endoloops or injection of sclerosing solutions (5-9).

Postpolypectomy bleeding can be mild mucosal oozing that ceases spontaneously or severe bleeding with resultant hypovolemia and hemodynamic instability. Antiplatelet agents (including aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], ticlopidine, clopidogrel, and glycoprotein IIb/IIIa receptor antagonists) and anticoagulants may increase the risk of postpolypectomy bleeding (10-12). Our patient had a history of warfarin use, and her international normalized ratio (INR) level was very high. Hui et al. (13) performed polypectomy in 1657 patients. There were 37 cases of polypectomy- associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use was an independent risk factor for bleeding. Anticoagulants, such as warfarin, should be stopped and the INR should be normalized before performing an elective colonoscopy in which therapeutic maneuvers are anticipated.

A postpolypectomy bleeding stalk has been conventionally treated with surgery or modalities like argon plasma coagulation, laser photocoagulation or bipolar electrocoagulation and hemoclip. EBL is an infrequently used modality for treatment of post polypectomy bleeding. Nijhawan et al. (14) reported the successful use of EBL for the management of postpolypectomy bleeding stalk. We report the successful use of this technique for the management of a postpolypectomy bleeding stalk with a gastroscope. The advantages of band ligation are its low cost, easy availability and ease of application.

Postpolypectomy bleeding can be mild mucosal oozing that ceases spontaneously or severe bleeding with resultant hypovolemia and hemodynamic instability. Antiplatelet agents (including aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], ticlopidine, clopidogrel, and glycoprotein IIb/IIIa receptor antagonists) and anticoagulants may increase the risk of postpolypectomy bleeding (10-12). Our patient had a history of warfarin use, and her international normalized ratio (INR) level was very high. Hui et al. (13) performed polypectomy in 1657 patients. There were 37 cases of polypectomy- associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use was an independent risk factor for bleeding. Anticoagulants, such as warfarin, should be stopped and the INR should be normalized before performing an elective colonoscopy in which therapeutic maneuvers are anticipated.

A postpolypectomy bleeding stalk has been conventionally treated with surgery or modalities like argon plasma coagulation, laser photocoagulation or bipolar electrocoagulation and hemoclip. EBL is an infrequently used modality for treatment of post polypectomy bleeding. Nijhawan et al. (14) reported the successful use of EBL for the management of postpolypectomy bleeding stalk. We report the successful use of this technique for the management of a postpolypectomy bleeding stalk with a gastroscope. The advantages of band ligation are its low cost, easy availability and ease of application.

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