Risk Factors for Delayed Bleeding After Cold Snare Polypectomy

Douglas K. Rex, MD, MASGE, reviewing Wen S, et al. Int J Colorectal Dis 2024 Jul 22.

Cold snare polypectomy reduces but does not eliminate the risk of delayed bleeding. In a retrospective analysis of 10,650 patients who underwent cold snare polypectomy in 4 Chinese centers between 2019 and 2023, there were 26 cases (0.24%) of delayed bleeding. Most patients presented with bleeding 0 to 5 days after polypectomy, on average, 1.58 days later. None of the patients required transfusion. 

In multivariate analyses, independent risk factors for delayed bleeding were hyperlipidemia, antithrombotic and antiplatelet use, history of abdominal surgery, sigmoid colon location, hematoma, larger wound size, more immediate bleeding at the time of resection, and pedunculated shape. A prediction model constructed on these factors performed very well in predicting risk, with area under the receiver operating characteristic curves of 0.912 (day 1), 0.939 (day 3), and 0.923 (day 5).

COMMENT

In clinical practice, the risk of delayed bleeding after cold snare polypectomy seems so low that it is easy to consider the procedure risk-free. However, there is a small but real risk of delayed bleeding after cold snare polypectomy. Among the predictive factors identified in this study, the endoscopic predictors (eg, sigmoid location, pedunculated shape, intraprocedural hematoma, or extensive bleeding) seem most valuable because they might lead to an intraprocedural action (clipping) to prevent delayed bleeding. Having said that, in our practice, we strive to minimize clip use after cold snaring, typically applying only clips for ongoing or severe bleeding that does not respond to direct pressure, grasping and squeezing the bleeding point with the snare, etc.

Importantly, none of the patients required transfusion. Thus, even when delayed bleeding occurs after cold snare polypectomy, bleeding seems generally less severe than that after snaring with electrocautery.