FIT for Post poLypectomy bLeeding Prediction

Why should one be concerned about delayed post polypectomy bleeding (DPPB)? One in 40 patients with polypectomy for large polyps will have it. A large systematic review of 50 studies including 6779 large polyps > 20mm resected by polypectomy, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), "en bloc" or in piece-meal have had an DPPB incidence of 2.6% (2.1% - 3.2%) [1].

Cand we generally predict what group of patients are more likely to have DPPB? Jaruvongvanich et al [2] have designed a meta-analysis of 12 studies on 14,313 patients. The pooled DPPB rate was 1.5% (0.7% - 3.4%). Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant DPPB risk factors, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not.

Huai et al [3] have designed a nomogram for DPPB prediction, based on 6 parameters, with a high AUC of 0.824 in the validation model, as in Figure 1, below. The model states that older men on anticoagulant, with pedunculated polyps on the right side are likely to bleed more often. Age, gender, and pedunculated morphology were included in the model, as risk factors, as opposed to previously mentioned paper [2]. The jury is probably still out for certain risk factors.

Yet, at the individual level, what could a patient do? Could a form of active surveillance for DPPB may be proposed?

Here's an idea. Fecal Immunochemical Test (FIT). FIT can detect minute quantities of hemoglobin in faces. It is used for colorectal cancer population screening in asymptomatic average risk individuals (eg. 50 to 75 years old) or in primary care in certain groups of symptomatic individuals, without overt rectal bleeding, as an adjunct decision tool for colonoscopy evaluation [5]. A recent meta-analysis on more than 6 million asymptomatic average risk individuals of which more than 2.6 million completed a screening FIT test have found a 5.4% positivity rate, an 85% colonoscopy completion rate, a 47.8% adenoma detection rate, a 25.3% advanced adenoma detection rate and a 5.1% colorectal cancer rate [6].