Bleed management during endoscopic resection – Part 3- Pedunculated polyp bleed

Key practical points with pedunculated polyps

1. As previously, position the patient so that base of the stalk lies opposite to gravity – this allows blood to pool away from bleed point and improves visibility and also makes snare positioning easier
2. Snare position for resection on stalk is important to achive clear margins and to make life easier to treat and post resection bleed as per picture below
3. For small, thinner, longer stalks – Forced Coagulation rather than Endocut(Blended cut) probably achieves better coagulation to prevent bleed . For significantly thicker, shorter stalks, Forced Coag may cause significant diathermy damage making histo interpretation difficult , so some preinjection into stalk and then Endocut Q may work better in such circumstances.
4. Pressure and duration of snare closure matter significantly to achieve right balance of cutting versus coagulation. Clear instruction to your assistant or doing this bit yourself may be better
5. Temporary hemostasis can be achieved by closing the snare around the remnant stalk and applying pressure. This will give some time for team to get the hemostatic device ready
6. As usual keep the field clear by constant wash with water jet/suction  and don’t allow blood to pool and clot
7. For spurting bleed – either clips or Coagulation grasper or bipolar hemostatic forceps work well