Delayed Bleeding Following Rectal LST Resection

Delayed Bleeding Following Rectal LST Resection.

Patient Background: 86 years patient underwent underwater mucosectomy for a rectal laterally spreading tumor (LST). In same session 3 LST in the right and left colon was treated with EMR and defect closure with clips.

Rectal Lesion was granular, flat-type, without invasive features, classified pre-operatively as NICE II / CONECCT IIa.

Procedure Details for under water EMR:

Endoscopic mucosal resection performed using underwater technique to optimize resection plane and reduce thermal injury.

No immediate bleeding or perforation observed.

Coagulation of visible vessel was done with the tip of the snare with soft coag 4.0

Defect left open with conservative clip placement due to good hemostasis at the time.

Postoperative Course:

On day 8 post-EMR, patient developed acute rectal bleeding at 3:00 AM.

Drop of hb by 2 points

Hemodynamically stable; bleeding characterized as moderate but persistent.

Emergency Management:

Urgent endoscopy performed under conscious sedation.

Active arterial bleeding noted from Rectal mucosal defect.

Other site of EMR was inspected and no stigmata of recent bleeding was observed

Hemostasis achieved using:

Coag grasper for precise vessel coagulation soft coag 4.0 until bleeding was controlled

Endoclips (4 units) to close the defect and secure hemostasis. 

Outcome:

Bleeding controlled successfully.

No further episodes observed during 48-hour monitoring.

Patient discharged with instructions for soft diet and close follow-up.

Teaching Points:

Delayed bleeding post-EMR can occur even after underwater technique, particularly in rectal LSTs. Overall average risk:  2–7% for colorectal EMR procedures.

Using a distal atachement cap help for better stability and sometimes hemostasis by tamponade.

Coag grasper combined with strategic clipping is highly effective for salvage hemostasis.

Importance of readiness for emergency endoscopy outside routine hours.