- Email: [email protected]
Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy
3). Although endoscopic forceps biopsies are obtained
quicker than endoscopic directed capsule biopsies, forceps biopsies are small, have significant crush artifact, and are obtained from the proximal duodenum which hampers interpretation.? However, in the Barakat et a1. study/4 98% of the endoscopic biopsies were adequate. Of the 111 samples obtained in the present study, 99% were of adequate quality. Of the other various methods, the steerable biopsy instrument appears most comparable in terms of length of procedure, success rate in obtaining tissue, and the high percentage of quality specimens. However, it has two disadvantages. Fluoroscopy and radiation exposure are required to place the instrument. Also, the steerable apparatus has a short life span, usually only 10 to 20 biopsy attempts. Thus, this study suggests the pediatric Crosby-Kugler capsule with two 1.5- x 2.0-mm ports directed by endoscopy is the method of choice in obtaining small bowel biopsies in children. This method is safe, quick, avoids radiation exposure, and results in high quality interpretable tissue specimens. REFERENCES 1. Crosby WH, Kugler HW. Intraluminal biopsy of the small intestine. Am J Dig Dis 1957;2:236-41. 2. Greene HL, Rosenweig NS, Lufkin EG, et al. Biopsy of the small intestine with a Crosby-Kugler capsule. Dig Dis 1974;19:189-98.
3. Partin JC, Shubert WK. Precautionary note on the use of intestinal biopsy capsule in infants and emaciated children. N Engl J Med 1966;274:94-5. 4. Kauder E, Bayless T. Peroral intestinal biopsy in children: a technique. Am J Dis Child 1964;107:582-5. 5. Carey JB. A simplified gastrointestinal biopsy capsule. Gastroenterology 1964;46:550-7. 6. Ament ME, Rubin CE. An infant multipurpose biopsy tube. Gastroenterology 1973;64:205-9. 7. Vanderhoof JA, Hunt LI, Antonson DL. Rapid biopsy procedures for small intestinal biopsy in infants and children. Gastroenterology 1981;80:938-41. 8. Ferry GD, Bendig DW. Peroral small bowel biopsies in infants and children using a directable biopsy instrument. Dig Dis Sci 1981;26:142-5. 9. Levy N, Stermer E. Endoscopic jejunal biopsy with the Crosby capsule. Br Med J 1984;288:1914-5. 10. Mullinger M, Wood BJ, Kliman MR, Robinson GC. Intramural hematoma of the duodenum: an unusual complication of small bowel biopsy. J Pediatr 1971;78:323-6. 11. McDonald WG. Perforation and hemorrhage after a gastrointestinal mucosal biopsy in a child. Gastroenterology 1966; 51:390-2. 12. Flick AL, Quinton WE, Rubin CEo Peroral hydraulic biopsy tube for multiple sampling at any level of the gastrointestinal tract. Gastroenterology 1961;40:120-6. 13. Clark SW. Jejunal perforation with the Crosby capsule. Lancet 1964;2:727-8. 14. Barakat MH, Ali SM, Badawi AR, et al. Peroral endoscopic duodenal biopsy in infants and children. Acta Paediatr Scand 1983;72:563-9. 15. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 16. Brandborg LL, Rubin CE, Quinton WE. A multipurpose instrument for suction biopsy of the esophagus, stomach, small bowel, and colon. Gastroenterology 1959;37:1-16. 17. Korn ER, Foroozin P. Endoscopic biopsies of normal duodenum mucosa. Gastrointest Endosc 1974;21:51-4.
Case Reports Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy W. S. Dyer, E. M. M. Quigley, S. M. Noel, K. E. Camacho, F. Manela, R. K. Zetterman,
MD MD MD MD MD MD
The procedure of electrocoagulating or hot biopsy has become a popular technique for endoscopic removal of small intestinal polyps.1-3 By grasping the From the Departments of Internal Medicine and Pathology and Microbiology, University of Nebraska Medical Center and Omaha Veterans Administration Medical Center, Omaha, Nebraska. Reprint requests: Eamonn M. M. Quigley, MD, Section of Digestive Diseases and Nutrition, University of Nebraska Medical Center, 600 South 42nd Street, Omaha, Nebraska 68198-2000. VOLUME 37, NO.3, 1991
polyp within the jaws of an insulated biopsy forceps and applying coagulating current, the stalk or base of the polyp is coagulated and the head removed intact for histological examination. 2 Pedunculated and sessile polyps less than 7 mm in diameter are commonly dealt with in this manner. Although this procedure is generally regarded as extremely safe, some recent evidence suggests that, when performed in the cecum and ascending colon, electrocoagulating biopsy may be associated with an appreciable risk of hemorrhage and perforation. 3-6 We report three cases of major colonic hemorrhage, each of which occurred following hot biopsy of diminutive polyps in the right colon. CASE REPORTS Patient 1 A 64-year-old man was referred for evaluation of chronic iron deficiency anemia. He had undergone three-vessel coronary artery bypass grafting 6 months previously and had been taking one 325-mg aspirin tablet daily for 6 months.
361
At colonoscopy, four polyps were identified: a 3 em in diameter sessile polyp at the hepatic flexure, a 2 em in diameter sessile sigmoid polyp, and a 1 em in diameter sessile polyp in the transverse colon were removed by snare polypectomy; the fourth, a 0.5-cm sessile polyp in the transverse colon was removed by hot biopsy. All of the removed polyps proved to be adenomas on histological examination; one demonstrated evidence of atypia. Colonoscopy was, therefore, repeated 3 months later. At this time, the only abnormality found was a 4-mm sessile polyp in the mid-ascending colon, which was removed by hot biopsy. Eight days later the patient developed profuse rectal bleeding and postural dizziness. Hemoglobin had fallen from 13.5 g/dl to 8.7 g/dl. Prothrombin time, partial thromboplastin time, and platelet count were all within normal range. Aspirin had been continued uninterrupted. Colonoscopy was repeated and revealed a 0.5-cm shallow ulcer with adherent clot in the midascending colon at the site of the recent hot biopsy. He was transfused 2 units of packed red blood cells, and there was no recurrence of gastrointestinal hemorrhage. Patient 2
A 74-year-old man underwent follow-up colonoscopy following removal of four colon polyps 12 months earlier. He had a history of angina pectoris and had been taking 162.5 mg of aspirin daily for 6 months. Five sessile polyps were found; a 3 mm in diameter polyp in the cecum, a 3 mm in diameter polyp in the mid-ascending colon, two 3 mm in diameter polyps in the mid-transverse colon, and a 5 mm in diameter polyp in the distal transverse colon. All were removed by hot biopsy. All polyps proved to be tubular adenomas on histological examination. Five days later, the patient developed profuse rectal hemorrhage accompanied by an orthostatic drop in blood pressure from 130/80 mm Hg supine to 90/70 mm Hg standing; pulse rising from 84 to 112 beats/min. He had continued to take aspirin in the same dose. Selective superior mesenteric angiography was performed and demonstrated immediate extravasation and pooling of contrast into the cecum (Fig. 1). Following transfusion of 5 units of packed red blood cells and in view of continuing lower gastrointestinal hemorrhage, laparotomy and right hemicolectomy were performed. Careful inspection of the opened colectomy specimen permitted identification of each of the recent hot biopsy sites. At the site of the previous cecal hot biopsy, a shallow ulcer with adherent blood clot and fibrin were noted. Histological examination of this area revealed an ulcer penetrating to the submucosa (Fig. 2). Inspection ofthe other hot biopsy site demonstrated superficial ulceration only; there was no evidence of recent hemorrhage. He had an uneventful recovery from surgery and has had no further episodes of bleeding. Patient 3
A 64-year-old man was referred for colonoscopy for evaluation of persistently Hemoccult-positive stools. He had long-standing chronic obstructive pulmonary disease and had been on prednisone in a dose of 10 mg daily for 6 months. Colonoscopy revealed four polyps: 5 mm and 2 mm in diameter sessile polyps in the cecum, a 7 mm in diameter sessile polyp in the ascending colon, and a 1.2 em in diameter pedunculated polyp in the sigmoid colon. The sessile polyps 362
Figure 1. Superior mesenteric angiogram from patient 2 demonstrates extravasation and pooling of contrast (arrow) in the cecum.
in the cecum and ascending colon were removed by hot biopsy and the 1.2 em in diameter sigmoid polyp by snare polypectomy. On histological examination the three sessile polyps proved to be tubular adenomas; the 1.2-cm pedunculated polyp in the sigmoid a villous adenoma. Six days later, the patient developed rectal bleeding and postural dizziness. Postural hypotension was present: systolic blood pressure falling from 132 mm Hg supine to 100 mm Hg standing. Hemoglobin had dropped from 12.5 g/dl at the time of colonoscopy to 10.5 g/dl. Prothrombin time, partial thromboplastin time, and platelet count were normal. A technetium-99m tagged red blood scan failed to reveal an active bleeding site. Repeat colonoscopy, without colonic lavage, was attempted, but the colonoscope could not be advanced beyond the mid-transverse colon due to the presence of feces. No active bleeding site or lesion bearing stigmata of recent hemorrhage was identified to the level of examination. The patient was transfused 2 units of blood; rectal hemorrhage stopped spontaneously and did not recur. Hot biopsy technique
All of these procedures were carried out with the Olympus CFV lOL colonoscope (Olympus Corporation of America, Lake Success, N. Y.) using an insulated electrocoagulating biopsy forceps (model FDIV; Olympus Corporation). A patient return electrode (Diatemp 2 Electrosurgical Dispersive Pad; NDM Corp., Dayton, Ohio) was placed on the right thigh. Coagulating current was applied in each instance for between 1 and 2 sec using a Valley Lab SSE2-K solid state electrosurgery unit (Valley Lab Ltd., Boulder, Colo.) with a setting of 3, at which time blanching of the base of the polyp was noted. Maintaining the biopsy forceps closed, a biopsy was removed from the polyp. Immediately following each biopsy, direct examination of the biopsy site revealed a wellcoagulated base without evidence of bleeding. On each occasion, the polyp was within full vision throughout the GASTROINTESTINAL ENDOSCOPY
Figure 2. Ulcerated area of colonic mucosa resulting from hot biopsy (between arrows) extending to muscularis propria (hematoxylin and eosin; original magnification x4). The boxed area is shown in the inset. Inset, Fibirinopurulent exudate overlies a large area of organizing hemorrhage (thin arrow) and submucosal vessel (broad arrow).
procedure, and particular care was taken to avoid contact between the exposed metal tip of the biopsy forceps and adjacent colonic mucosa.
DISCUSSION
In this report, we describe three patients who developed a major colonic hemorrhage following endoscopic electrocoagulating biopsy (hot biopsy) of diminutive colonic polyps. All three patients developed symptomatic postural hypotension, all received blood transfusions and one of the three required an emergency right hemicolectomy to arrest bleeding. In two of the three patients, the colonic hemorrhage was defined as originating from the prior hot biopsy site; by angiography as well as gross and microscopic inspection of a colectomy specimen in one and by colonoscopic inspection in the other. In the third patient, although the right colon was not reached at attempted colonoscopy, it seems reasonable to assume that the hemorrhage originated from one of the three hot biopsy sites in the right colon as there was no evidence of active or recent hemorrhage from the sigmoid polypectomy site. All of the polyps removed by hot biopsy were within the size range considered to be safe for performance of the procedure, and the biopsy technique, current setting, and duration of application were well in line with standard recommendations. 1- 3 In a previous report, we described an episode of massive, fatal hemorrhage in a patient who had undergone hot biopsy of a diminutive cecal polyp.6 Pathological examination, VOLUME 37, NO.3, 1991
in that instance, revealed deep ulceration in the cecum, eroding an unusually large submucosal artery. Based on these pathological findings, on the presence of a burned area at the distal end of the insulating, outer cover of the hot biopsy forceps, and on in vitro tests of the hot biopsy apparatus, we concluded that contact and short-circuiting between normal mucosa adjacent to the biopsied polyp and the metal tip of the biopsy forceps resulted in deep coagulation necrosis. 6 However, in the three cases in this report, there was no evidence of any defect in the hot biopsy forceps, direct visualization of the polyps and surrounding mucosa had been maintained during each procedure, and there was no macroscopic or pathological evidence of a short-circuit injury to adjacent mucosa. It is noteworthy also that all episodes of hemorrhage originated from the right colon, even though hot biopsies and snare diathermy polypectomies had been performed in the transverse and sigmoid colon in each patient, suggesting that the cecum and ascending colon may be predisposed to this complication. Indeed, in a large survey, Wadas and Sanowski5 described an increased incidence of both hemorrhage and perforation following electrocoagulating biopsy in the right colon. They suggested that the commonly used power settings and duration of current application were too high for the relatively thin-walled right colon. Furthermore, studies of monopolar electrocoagulation have illustrated the variability of depth of tissue injury associated with this modality, emphasizing the need for extreme caution in high risk areas. 7- 9 363
Two of the patients, including the patient who required emergency colectomy, had been taking lowdose aspirin for ischemic heart disease. Although all three patients had normal platelet counts and normal prothrombin and partial thromboplastin times, neither bleeding times nor platelet function studies were performed. It is possible that low-dose aspirin therapy, by its known effects on platelet function,lO contributed to the delayed hemorrhage. Thus, in a recent study, Sethi et al. 11 documented significantly increased postoperative bleeding following coronary artery bypass grafting in patients who had received a single 325-mg aspirin tablet pre-operatively. While increased postoperative bleeding has been noted by others following major surgical procedures/ 2- 16 low-dose aspirin therapy has not been previously associated with abnormal bleeding following endoscopic biopsies, either hot or cold. Of a total of 2500 colonoscopic examinations performed by our gastroenterology division over the past 3 years, four episodes of major post-colonoscopic hemorrhage have occurred. All have been related to hot biopsy procedures in the right colon. One was reported previously,6 and the other three comprise this report. None have followed cautery snare polypectomy. It is also striking that two of these patients had been taking low-dose aspirin. Also noteworthy is the timing of the hemorrhage, which was delayed on each occasion, occurring between 6 and 10 days after hot biopsy. Taken together with our previous report6 and with the findings of Wadas and Sanowski,5 this report serves to emphasize the increased risk of hemorrhage following endoscopic coagulation or hot biopsy in the cecum and ascending colon. Therapy with low-dose aspirin may have been an additional risk factor in two of these patients. Therefore, we suggest the following. First, every attempt should be made to identify increased risk for hemorrhage before embarking on hot biopsy in the right colon. Second, strict attention should be given to the power setting and duration of current application. Finally, consideration should be given to discontinuing low-dose aspirin before colon-
364
oscopy. Large prospective studies are urgently required to determine the true risks for hot biopsy in the right colon and in the presence of low-dose aspirin therapy.
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. Oxford: Blackwell Scientific Publications, 1981:147-54. 2. Cohen LB, Waye JD. Treatment of colonic polyps-practical considerations. Clin GastroenteroI1986;15:359-76. 3. Williams CB. The use of hot biopsy. Endosc Rev 1985;2:12-7. 4. Rand AA. Hemorrhage following coagulation-biopsy of larger than diminutive polyps of the cecum: report of 2 cases. Gastrointest Endosc 1977;23:239. 5. Wadas DD, Sanowski RA. Complications of the hot biopsy forceps technique. Gastrointest Endosc 1988;34:32-7. 6. Quigley EMM, Donovan JP, Linder J, Thompson JS, Straub PF, Paustian FF. Delayed, massive hemorrhage following electrocoagulating biopsy ("hot biopsy") of a diminutive colonic biopsy. Gastrointest Endosc 1989;35:559-63. 7. Protell RL, Gilbert DA, Silverstein FE, Jensen DM, Hulett FM, Auth DC. Computer assisted electrocoagulation: bipolar versus monopolar in the treatment of experimental gastric ulcer bleeding. Gastroenterology 1981;81:454-5. 8. Swain CP, Mills TM, Shemesh E, et al. Which electrode? A comparison of four methods of electrocoagulation in experimental bleeding ulcers. Gut 1984;25:1424-31. 9. Johnson JH, Jensen DM, Mautner W. Comparison of endoscopic electrocoagulation and laser photocoagulation of bleeding canine gastric ulcers. Gastroenterology 1982;82:904-10. 10. Patrono C. Aspirin and human platelets: from clinical trials to acetylation of cyciooxygenase and back. Trends Pharmacol Sci 1989;10:453-8. 11. Sethi GK, Copeland JG, Goldman S, Moritz T, Zadina K, Henderson WG. Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. J Am Coil Cardiol 1990;15:15-20. 12. Michelson EL, Morganroth J, Torosian M, MacVaughn H III. Relation of preoperative use of aspirin to increased mediastinal blood loss after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 1978;76:694-7. 13. Kitchen L, Erichson RB, Siderpoulos H. Effect of drug-induced platelet dysfunction on surgical bleeding. Am J Surg 1982;143:215-7. 14. Torosian M, Michelson EL, Morganroth J, MacVaughn H III. Aspirin and coumadin-related bleeding after coronary artery bypass graft surgery. Ann Intern Med 1978;89:325-8. 15. Ferraris VA, Swanson E. Aspirin usage and perioperative blood loss in patients undergoing unexpected operations. Surg Gynecol Obstet 1983;156:439-42. 16. Ferraris VA, Ferraris SP, Lough FC, Berry WR. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg 1988;45:71-9.
GASTROINTESTINAL ENDOSCOPY
quicker than endoscopic directed capsule biopsies, forceps biopsies are small, have significant crush artifact, and are obtained from the proximal duodenum which hampers interpretation.? However, in the Barakat et a1. study/4 98% of the endoscopic biopsies were adequate. Of the 111 samples obtained in the present study, 99% were of adequate quality. Of the other various methods, the steerable biopsy instrument appears most comparable in terms of length of procedure, success rate in obtaining tissue, and the high percentage of quality specimens. However, it has two disadvantages. Fluoroscopy and radiation exposure are required to place the instrument. Also, the steerable apparatus has a short life span, usually only 10 to 20 biopsy attempts. Thus, this study suggests the pediatric Crosby-Kugler capsule with two 1.5- x 2.0-mm ports directed by endoscopy is the method of choice in obtaining small bowel biopsies in children. This method is safe, quick, avoids radiation exposure, and results in high quality interpretable tissue specimens. REFERENCES 1. Crosby WH, Kugler HW. Intraluminal biopsy of the small intestine. Am J Dig Dis 1957;2:236-41. 2. Greene HL, Rosenweig NS, Lufkin EG, et al. Biopsy of the small intestine with a Crosby-Kugler capsule. Dig Dis 1974;19:189-98.
3. Partin JC, Shubert WK. Precautionary note on the use of intestinal biopsy capsule in infants and emaciated children. N Engl J Med 1966;274:94-5. 4. Kauder E, Bayless T. Peroral intestinal biopsy in children: a technique. Am J Dis Child 1964;107:582-5. 5. Carey JB. A simplified gastrointestinal biopsy capsule. Gastroenterology 1964;46:550-7. 6. Ament ME, Rubin CE. An infant multipurpose biopsy tube. Gastroenterology 1973;64:205-9. 7. Vanderhoof JA, Hunt LI, Antonson DL. Rapid biopsy procedures for small intestinal biopsy in infants and children. Gastroenterology 1981;80:938-41. 8. Ferry GD, Bendig DW. Peroral small bowel biopsies in infants and children using a directable biopsy instrument. Dig Dis Sci 1981;26:142-5. 9. Levy N, Stermer E. Endoscopic jejunal biopsy with the Crosby capsule. Br Med J 1984;288:1914-5. 10. Mullinger M, Wood BJ, Kliman MR, Robinson GC. Intramural hematoma of the duodenum: an unusual complication of small bowel biopsy. J Pediatr 1971;78:323-6. 11. McDonald WG. Perforation and hemorrhage after a gastrointestinal mucosal biopsy in a child. Gastroenterology 1966; 51:390-2. 12. Flick AL, Quinton WE, Rubin CEo Peroral hydraulic biopsy tube for multiple sampling at any level of the gastrointestinal tract. Gastroenterology 1961;40:120-6. 13. Clark SW. Jejunal perforation with the Crosby capsule. Lancet 1964;2:727-8. 14. Barakat MH, Ali SM, Badawi AR, et al. Peroral endoscopic duodenal biopsy in infants and children. Acta Paediatr Scand 1983;72:563-9. 15. Scott BB, Jenkins D. Endoscopic small intestinal biopsy. Gastrointest Endosc 1981;27:162-7. 16. Brandborg LL, Rubin CE, Quinton WE. A multipurpose instrument for suction biopsy of the esophagus, stomach, small bowel, and colon. Gastroenterology 1959;37:1-16. 17. Korn ER, Foroozin P. Endoscopic biopsies of normal duodenum mucosa. Gastrointest Endosc 1974;21:51-4.
Case Reports Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy W. S. Dyer, E. M. M. Quigley, S. M. Noel, K. E. Camacho, F. Manela, R. K. Zetterman,
MD MD MD MD MD MD
The procedure of electrocoagulating or hot biopsy has become a popular technique for endoscopic removal of small intestinal polyps.1-3 By grasping the From the Departments of Internal Medicine and Pathology and Microbiology, University of Nebraska Medical Center and Omaha Veterans Administration Medical Center, Omaha, Nebraska. Reprint requests: Eamonn M. M. Quigley, MD, Section of Digestive Diseases and Nutrition, University of Nebraska Medical Center, 600 South 42nd Street, Omaha, Nebraska 68198-2000. VOLUME 37, NO.3, 1991
polyp within the jaws of an insulated biopsy forceps and applying coagulating current, the stalk or base of the polyp is coagulated and the head removed intact for histological examination. 2 Pedunculated and sessile polyps less than 7 mm in diameter are commonly dealt with in this manner. Although this procedure is generally regarded as extremely safe, some recent evidence suggests that, when performed in the cecum and ascending colon, electrocoagulating biopsy may be associated with an appreciable risk of hemorrhage and perforation. 3-6 We report three cases of major colonic hemorrhage, each of which occurred following hot biopsy of diminutive polyps in the right colon. CASE REPORTS Patient 1 A 64-year-old man was referred for evaluation of chronic iron deficiency anemia. He had undergone three-vessel coronary artery bypass grafting 6 months previously and had been taking one 325-mg aspirin tablet daily for 6 months.
361
At colonoscopy, four polyps were identified: a 3 em in diameter sessile polyp at the hepatic flexure, a 2 em in diameter sessile sigmoid polyp, and a 1 em in diameter sessile polyp in the transverse colon were removed by snare polypectomy; the fourth, a 0.5-cm sessile polyp in the transverse colon was removed by hot biopsy. All of the removed polyps proved to be adenomas on histological examination; one demonstrated evidence of atypia. Colonoscopy was, therefore, repeated 3 months later. At this time, the only abnormality found was a 4-mm sessile polyp in the mid-ascending colon, which was removed by hot biopsy. Eight days later the patient developed profuse rectal bleeding and postural dizziness. Hemoglobin had fallen from 13.5 g/dl to 8.7 g/dl. Prothrombin time, partial thromboplastin time, and platelet count were all within normal range. Aspirin had been continued uninterrupted. Colonoscopy was repeated and revealed a 0.5-cm shallow ulcer with adherent clot in the midascending colon at the site of the recent hot biopsy. He was transfused 2 units of packed red blood cells, and there was no recurrence of gastrointestinal hemorrhage. Patient 2
A 74-year-old man underwent follow-up colonoscopy following removal of four colon polyps 12 months earlier. He had a history of angina pectoris and had been taking 162.5 mg of aspirin daily for 6 months. Five sessile polyps were found; a 3 mm in diameter polyp in the cecum, a 3 mm in diameter polyp in the mid-ascending colon, two 3 mm in diameter polyps in the mid-transverse colon, and a 5 mm in diameter polyp in the distal transverse colon. All were removed by hot biopsy. All polyps proved to be tubular adenomas on histological examination. Five days later, the patient developed profuse rectal hemorrhage accompanied by an orthostatic drop in blood pressure from 130/80 mm Hg supine to 90/70 mm Hg standing; pulse rising from 84 to 112 beats/min. He had continued to take aspirin in the same dose. Selective superior mesenteric angiography was performed and demonstrated immediate extravasation and pooling of contrast into the cecum (Fig. 1). Following transfusion of 5 units of packed red blood cells and in view of continuing lower gastrointestinal hemorrhage, laparotomy and right hemicolectomy were performed. Careful inspection of the opened colectomy specimen permitted identification of each of the recent hot biopsy sites. At the site of the previous cecal hot biopsy, a shallow ulcer with adherent blood clot and fibrin were noted. Histological examination of this area revealed an ulcer penetrating to the submucosa (Fig. 2). Inspection ofthe other hot biopsy site demonstrated superficial ulceration only; there was no evidence of recent hemorrhage. He had an uneventful recovery from surgery and has had no further episodes of bleeding. Patient 3
A 64-year-old man was referred for colonoscopy for evaluation of persistently Hemoccult-positive stools. He had long-standing chronic obstructive pulmonary disease and had been on prednisone in a dose of 10 mg daily for 6 months. Colonoscopy revealed four polyps: 5 mm and 2 mm in diameter sessile polyps in the cecum, a 7 mm in diameter sessile polyp in the ascending colon, and a 1.2 em in diameter pedunculated polyp in the sigmoid colon. The sessile polyps 362
Figure 1. Superior mesenteric angiogram from patient 2 demonstrates extravasation and pooling of contrast (arrow) in the cecum.
in the cecum and ascending colon were removed by hot biopsy and the 1.2 em in diameter sigmoid polyp by snare polypectomy. On histological examination the three sessile polyps proved to be tubular adenomas; the 1.2-cm pedunculated polyp in the sigmoid a villous adenoma. Six days later, the patient developed rectal bleeding and postural dizziness. Postural hypotension was present: systolic blood pressure falling from 132 mm Hg supine to 100 mm Hg standing. Hemoglobin had dropped from 12.5 g/dl at the time of colonoscopy to 10.5 g/dl. Prothrombin time, partial thromboplastin time, and platelet count were normal. A technetium-99m tagged red blood scan failed to reveal an active bleeding site. Repeat colonoscopy, without colonic lavage, was attempted, but the colonoscope could not be advanced beyond the mid-transverse colon due to the presence of feces. No active bleeding site or lesion bearing stigmata of recent hemorrhage was identified to the level of examination. The patient was transfused 2 units of blood; rectal hemorrhage stopped spontaneously and did not recur. Hot biopsy technique
All of these procedures were carried out with the Olympus CFV lOL colonoscope (Olympus Corporation of America, Lake Success, N. Y.) using an insulated electrocoagulating biopsy forceps (model FDIV; Olympus Corporation). A patient return electrode (Diatemp 2 Electrosurgical Dispersive Pad; NDM Corp., Dayton, Ohio) was placed on the right thigh. Coagulating current was applied in each instance for between 1 and 2 sec using a Valley Lab SSE2-K solid state electrosurgery unit (Valley Lab Ltd., Boulder, Colo.) with a setting of 3, at which time blanching of the base of the polyp was noted. Maintaining the biopsy forceps closed, a biopsy was removed from the polyp. Immediately following each biopsy, direct examination of the biopsy site revealed a wellcoagulated base without evidence of bleeding. On each occasion, the polyp was within full vision throughout the GASTROINTESTINAL ENDOSCOPY
Figure 2. Ulcerated area of colonic mucosa resulting from hot biopsy (between arrows) extending to muscularis propria (hematoxylin and eosin; original magnification x4). The boxed area is shown in the inset. Inset, Fibirinopurulent exudate overlies a large area of organizing hemorrhage (thin arrow) and submucosal vessel (broad arrow).
procedure, and particular care was taken to avoid contact between the exposed metal tip of the biopsy forceps and adjacent colonic mucosa.
DISCUSSION
In this report, we describe three patients who developed a major colonic hemorrhage following endoscopic electrocoagulating biopsy (hot biopsy) of diminutive colonic polyps. All three patients developed symptomatic postural hypotension, all received blood transfusions and one of the three required an emergency right hemicolectomy to arrest bleeding. In two of the three patients, the colonic hemorrhage was defined as originating from the prior hot biopsy site; by angiography as well as gross and microscopic inspection of a colectomy specimen in one and by colonoscopic inspection in the other. In the third patient, although the right colon was not reached at attempted colonoscopy, it seems reasonable to assume that the hemorrhage originated from one of the three hot biopsy sites in the right colon as there was no evidence of active or recent hemorrhage from the sigmoid polypectomy site. All of the polyps removed by hot biopsy were within the size range considered to be safe for performance of the procedure, and the biopsy technique, current setting, and duration of application were well in line with standard recommendations. 1- 3 In a previous report, we described an episode of massive, fatal hemorrhage in a patient who had undergone hot biopsy of a diminutive cecal polyp.6 Pathological examination, VOLUME 37, NO.3, 1991
in that instance, revealed deep ulceration in the cecum, eroding an unusually large submucosal artery. Based on these pathological findings, on the presence of a burned area at the distal end of the insulating, outer cover of the hot biopsy forceps, and on in vitro tests of the hot biopsy apparatus, we concluded that contact and short-circuiting between normal mucosa adjacent to the biopsied polyp and the metal tip of the biopsy forceps resulted in deep coagulation necrosis. 6 However, in the three cases in this report, there was no evidence of any defect in the hot biopsy forceps, direct visualization of the polyps and surrounding mucosa had been maintained during each procedure, and there was no macroscopic or pathological evidence of a short-circuit injury to adjacent mucosa. It is noteworthy also that all episodes of hemorrhage originated from the right colon, even though hot biopsies and snare diathermy polypectomies had been performed in the transverse and sigmoid colon in each patient, suggesting that the cecum and ascending colon may be predisposed to this complication. Indeed, in a large survey, Wadas and Sanowski5 described an increased incidence of both hemorrhage and perforation following electrocoagulating biopsy in the right colon. They suggested that the commonly used power settings and duration of current application were too high for the relatively thin-walled right colon. Furthermore, studies of monopolar electrocoagulation have illustrated the variability of depth of tissue injury associated with this modality, emphasizing the need for extreme caution in high risk areas. 7- 9 363
Two of the patients, including the patient who required emergency colectomy, had been taking lowdose aspirin for ischemic heart disease. Although all three patients had normal platelet counts and normal prothrombin and partial thromboplastin times, neither bleeding times nor platelet function studies were performed. It is possible that low-dose aspirin therapy, by its known effects on platelet function,lO contributed to the delayed hemorrhage. Thus, in a recent study, Sethi et al. 11 documented significantly increased postoperative bleeding following coronary artery bypass grafting in patients who had received a single 325-mg aspirin tablet pre-operatively. While increased postoperative bleeding has been noted by others following major surgical procedures/ 2- 16 low-dose aspirin therapy has not been previously associated with abnormal bleeding following endoscopic biopsies, either hot or cold. Of a total of 2500 colonoscopic examinations performed by our gastroenterology division over the past 3 years, four episodes of major post-colonoscopic hemorrhage have occurred. All have been related to hot biopsy procedures in the right colon. One was reported previously,6 and the other three comprise this report. None have followed cautery snare polypectomy. It is also striking that two of these patients had been taking low-dose aspirin. Also noteworthy is the timing of the hemorrhage, which was delayed on each occasion, occurring between 6 and 10 days after hot biopsy. Taken together with our previous report6 and with the findings of Wadas and Sanowski,5 this report serves to emphasize the increased risk of hemorrhage following endoscopic coagulation or hot biopsy in the cecum and ascending colon. Therapy with low-dose aspirin may have been an additional risk factor in two of these patients. Therefore, we suggest the following. First, every attempt should be made to identify increased risk for hemorrhage before embarking on hot biopsy in the right colon. Second, strict attention should be given to the power setting and duration of current application. Finally, consideration should be given to discontinuing low-dose aspirin before colon-
364
oscopy. Large prospective studies are urgently required to determine the true risks for hot biopsy in the right colon and in the presence of low-dose aspirin therapy.
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. Oxford: Blackwell Scientific Publications, 1981:147-54. 2. Cohen LB, Waye JD. Treatment of colonic polyps-practical considerations. Clin GastroenteroI1986;15:359-76. 3. Williams CB. The use of hot biopsy. Endosc Rev 1985;2:12-7. 4. Rand AA. Hemorrhage following coagulation-biopsy of larger than diminutive polyps of the cecum: report of 2 cases. Gastrointest Endosc 1977;23:239. 5. Wadas DD, Sanowski RA. Complications of the hot biopsy forceps technique. Gastrointest Endosc 1988;34:32-7. 6. Quigley EMM, Donovan JP, Linder J, Thompson JS, Straub PF, Paustian FF. Delayed, massive hemorrhage following electrocoagulating biopsy ("hot biopsy") of a diminutive colonic biopsy. Gastrointest Endosc 1989;35:559-63. 7. Protell RL, Gilbert DA, Silverstein FE, Jensen DM, Hulett FM, Auth DC. Computer assisted electrocoagulation: bipolar versus monopolar in the treatment of experimental gastric ulcer bleeding. Gastroenterology 1981;81:454-5. 8. Swain CP, Mills TM, Shemesh E, et al. Which electrode? A comparison of four methods of electrocoagulation in experimental bleeding ulcers. Gut 1984;25:1424-31. 9. Johnson JH, Jensen DM, Mautner W. Comparison of endoscopic electrocoagulation and laser photocoagulation of bleeding canine gastric ulcers. Gastroenterology 1982;82:904-10. 10. Patrono C. Aspirin and human platelets: from clinical trials to acetylation of cyciooxygenase and back. Trends Pharmacol Sci 1989;10:453-8. 11. Sethi GK, Copeland JG, Goldman S, Moritz T, Zadina K, Henderson WG. Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. J Am Coil Cardiol 1990;15:15-20. 12. Michelson EL, Morganroth J, Torosian M, MacVaughn H III. Relation of preoperative use of aspirin to increased mediastinal blood loss after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 1978;76:694-7. 13. Kitchen L, Erichson RB, Siderpoulos H. Effect of drug-induced platelet dysfunction on surgical bleeding. Am J Surg 1982;143:215-7. 14. Torosian M, Michelson EL, Morganroth J, MacVaughn H III. Aspirin and coumadin-related bleeding after coronary artery bypass graft surgery. Ann Intern Med 1978;89:325-8. 15. Ferraris VA, Swanson E. Aspirin usage and perioperative blood loss in patients undergoing unexpected operations. Surg Gynecol Obstet 1983;156:439-42. 16. Ferraris VA, Ferraris SP, Lough FC, Berry WR. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg 1988;45:71-9.
GASTROINTESTINAL ENDOSCOPY