Hwang JH, Hyun HK, Gwon SH, Son NH, Huh CW. Immediate post-polypectomy bleeding is associated with an increased risk of delayed post-polypectomy bleeding: A large retrospective cohort study. World J Gastroenterol 2026; 32(24): 118775 [DOI: 10.3748/wjg.118775]
Corresponding Author of This Article
Cheal Wung Huh, MD, PhD, Associate Professor, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363, Dongbaekjukjeon-daero, Giheung-gu, Yongin-si, Yongin 16995, Gyeonggi-do, South Korea. huhcw@yuhs.ac
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Hwang JH, Hyun HK, Gwon SH, Son NH, Huh CW. Immediate post-polypectomy bleeding is associated with an increased risk of delayed post-polypectomy bleeding: A large retrospective cohort study. World J Gastroenterol 2026; 32(24): 118775 [DOI: 10.3748/wjg.118775]
Jin Ho Hwang, Hye Kyung Hyun, Cheal Wung Huh, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Gyeonggi-do, South Korea
So Hyeon Gwon, Nak-Hoon Son, Department of Statistics, Keimyung University, Daegu 42601, South Korea
Co-first authors: Jin Ho Hwang and Hye Kyung Hyun.
Co-corresponding authors: Nak-Hoon Son and Cheal Wung Huh.
Author contributions: Hwang JH, Hyun HK, and Huh CW designed the study, wrote and revised the manuscript; Hwang JH, Hyun HK, Son NH, Gwon SH, and Huh CW participated in the formal analysis and investigation; all authors have read and approved the final manuscript.
Institutional review board statement: The study was approved by the Institutional Review Board of Yongin Severance Hospital (approval No. 9-2025-0210; date of registration: December 23, 2025).
Informed consent statement: Owing to the retrospective study design, the requirement for informed consent was waived.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: The corresponding author will share the data underlying this article at a reasonable request.
Corresponding author: Cheal Wung Huh, MD, PhD, Associate Professor, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363, Dongbaekjukjeon-daero, Giheung-gu, Yongin-si, Yongin 16995, Gyeonggi-do, South Korea. huhcw@yuhs.ac
Received: January 12, 2026 Revised: February 3, 2026 Accepted: March 3, 2026 Published online: June 28, 2026 Processing time: 153 Days and 7.2 Hours
Abstract
BACKGROUND
Post-polypectomy bleeding is a common adverse event associated with colonoscopic polypectomy. Although various risk factors for delayed post-polypectomy bleeding (DPPB) have been identified, the relationship between immediate post-polypectomy bleeding (IPPB) and subsequent DPPB risk remains unclear. Furthermore, risk factors for DPPB specifically among patients who experience IPPB have not been systematically evaluated.
AIM
To investigate the association between IPPB and DPPB, hypothesizing that patients experiencing IPPB would have a higher risk of subsequent DPPB, and to identify independent risk factors for DPPB among patients who experienced IPPB.
METHODS
In this retrospective cohort study, we analyzed the data of patients who underwent colonoscopic polypectomies in the Republic of Korea between 2005 and 2022. Information on multiple covariates, including patient-, polyp-, and procedure-related factors, was collected. Patients were categorized based on IPPB occurrence, and DPPB incidence was compared between the groups. The McNemar test was used to assess the association between IPPB and DPPB. Logistic regression analysis was used to identify risk factors for DPPB among patients with IPPB.
RESULTS
Of the 16684 patients included, 933 (5.59%) experienced IPPB and 15751 (94.41%) did not. Among patients with IPPB, 35 (3.75%) developed DPPB, whereas 246 (1.56%) of patients without IPPB developed DPPB, demonstrating a statistically significant positive association between IPPB and DPPB [paired odds ratio (OR) = 3.65, 95% confidence interval (CI): 3.17-4.20, P < 0.001]. Following multivariable analysis among patients with IPPB, trainee-performed procedures was identified as the only independent risk factor for DPPB (OR = 3.091, 95%CI: 1.037-9.219, P = 0.043).
CONCLUSION
IPPB occurrence is significantly associated with an increased risk of DPPB, suggesting the need for careful preventive strategies, particularly for procedures performed by trainees.
Core Tip: Post-polypectomy bleeding is one of the most common adverse effects in colonoscopic polypectomies. In our study, we found that patients with immediate post-polypectomy bleeding have a higher risk of developing delayed post-polypectomy bleeding. Procedures performed by trainees were associated with a higher risk of delayed post-polypectomy bleeding, highlighting the need for careful preventive strategies, particularly in procedures performed by trainees.
Citation: Hwang JH, Hyun HK, Gwon SH, Son NH, Huh CW. Immediate post-polypectomy bleeding is associated with an increased risk of delayed post-polypectomy bleeding: A large retrospective cohort study. World J Gastroenterol 2026; 32(24): 118775
Colorectal cancer, a major cause of global morbidity and mortality, has the third highest incidence among all cancers and contributes substantially to cancer-related deaths[1,2]. Colonoscopic polypectomy has become the cornerstone strategy for reducing the incidence and associated mortality of colorectal cancer[3-7]. Despite its established clinical benefits, colonoscopic polypectomy can result in adverse events such as post-polypectomy bleeding (PPB), perforation, and coagulation syndrome following the procedure. Among these, PPB represents the most frequent complication, with an incidence rate of approximately 0.3%-6.1% of all cases[8-10].
PPB can be classified into immediate PPB (IPPB) and delayed PPB (DPPB). IPPB refers to bleeding that persists for at least 1 minute or presents as active spurting immediately after polyp resection[11,12]. Although IPPB occurs in approximately 2.8% of colonoscopic polypectomies, most cases can be effectively managed with immediate endoscopic hemostatic interventions, including hemoclip application, cauterization, and epinephrine injection[11,13]. In contrast, DPPB is defined as bleeding occurring between procedure completion and 30 days post-polypectomy, requiring emergency department visits, hospitalization, or repeat endoscopic interventions[14]. Although DPPB occurs less frequently, with incidence rates of 0.3%-1.5%, patients may require emergency care, blood transfusion, or even surgical intervention[9,14,15]. Therefore, identifying the risk factors for DPPB is important for preventing adverse events and optimizing outcomes in patients with elevated bleeding risk.
Although previous studies have reported the risk factors for DPPB, such as pedunculated polyp morphology, polyp size > 10 mm, right-sided location, thrombocytopenia, chronic kidney disease, anticoagulant use, and hypertension[14-20], few studies have specifically examined the association between IPPB and DPPB. Existing literature on this relationship has several critical limitations, including small sample sizes and a failure to fully account for important confounding factors such as medication use, comorbidities, laboratory findings, and endoscopic procedural characteristics[13,21]. Furthermore, previous studies have not focused specifically on patients who have experienced IPPB, nor investigated the risk factors within this subgroup that may further increase the risk of subsequent DPPB. Therefore, clarifying the association between IPPB and DPPB and identifying the risk factors of DPPB among patients with IPPB are essential for developing risk-stratified post-polypectomy surveillance and preventive strategies. To our knowledge, no previous study has systematically evaluated the independent risk factors for DPPB in patients with IPPB.
Accordingly, the aim of this study was to investigate the association between IPPB occurrence and DPPB risk and identify independent risk factors for DPPB among patients who experienced IPPB in a large cohort that underwent colonoscopic polypectomy.
MATERIALS AND METHODS
Data source
Data were extracted from the Severance Clinical Research Analysis Portal, an institutional clinical research database that systematically collects and analyzes clinical information based on predefined protocols. The database contains anonymized records of over 6.5 million patients accumulated since November 2005. Available data elements include patient demographics, comorbidities, family history, diagnostic codes, imaging findings, laboratory values, and pathological results, all linked through unique patient and visit identifiers. We retrospectively reviewed records of patients who underwent colorectal polypectomy at Severance Hospital and Yongin Severance Hospital in South Korea. This study was conducted in accordance with the Declaration of Helsinki (1975) and was approved by the Institutional Review Board of Yongin Severance Hospital (IRB No. 9-2025-0210; date of registration: December 23, 2025). Given the retrospective nature of this study, the requirement for individual informed consent was waived.
Patients and study design
This multicenter retrospective cohort study included 21562 patients who received colonoscopy with polypectomy between November 2005 and June 2022. Patients aged 18 years or older who underwent polypectomy during colonoscopy were eligible for enrollment. Exclusion criteria included age younger than 18 years, incomplete clinical or laboratory data, history of bowel resection, inflammatory bowel disease, and familial adenomatous polyposis. After applying the exclusion criteria, 41279 polyps in 16684 patients were included in the final analysis.
Patients on antiplatelet therapy were advised to withhold these medications for five to seven days before the scheduled procedure to reduce periprocedural bleeding. Likewise, direct oral anticoagulants were held for 48 hours preceding the procedure. Based on individual patient circumstances, anticoagulants were temporarily substituted with heparin as part of a personalized management strategy. After polypectomy, the endoscopist evaluated the optimal timing for resuming antiplatelet or anticoagulant therapy, which was restarted promptly according to established guidelines[22-24]. All patients were prepared for colonoscopy by ingesting 2 L or 4 L of polyethylene glycol electrolyte solution before the procedure. During endoscopy with conscious sedation, midazolam was administered intravenously at a dose of 0.05-0.07 mg/kg. Additional doses of midazolam (1-3 mg) or propofol (10-20 mg) were administered as required to sustain sedation at the discretion of the endoscopist. All polypectomies were performed by a gastroenterologist using high-definition colonoscopy equipment (CF H260AL, CF H260AI, CF-H290 L, CF-HQ290I, and GIF-HQ290; Olympus Optical, Tokyo, Japan). After the procedure, all patients attended an outpatient follow-up appointment within four weeks.
Covariates
Patient-related variables: Patient-related factors, including age, sex, body mass index (BMI), medical history, laboratory results, and medication use, were systematically collected and analyzed. The medications evaluated included antiplatelet agents (aspirin, clopidogrel, prasugrel, and ticagrelor), anticoagulants (warfarin and direct oral anticoagulants), nonsteroidal anti-inflammatory drugs, and corticosteroids. The documented comorbidities included hypertension, diabetes mellitus, liver cirrhosis or chronic liver disease, cardiovascular disease, cerebrovascular disease, chronic kidney disease, and various malignancies. Laboratory assessments included hemoglobin levels, platelet counts, and coagulation parameters such as prothrombin time, partial thromboplastin time, and international normalized ratio, providing a comprehensive evaluation of hemostatic status.
Polyp-related variables: Polyp-related factors, including the size, morphology, location, number, and histopathological findings from colorectal polypectomy specimens, were evaluated. Polyp distribution was classified as right-sided (cecum, ascending colon, and transverse colon), left-sided (descending colon and sigmoid colon), or rectal. The size of each polyp was estimated using fully open biopsy forceps with a 7-mm gap. Polyps were classified according to the modified Japanese Research Society Classification criteria[25]. Morphological assessment was based on the presence or absence of a stalk, categorizing polyps as pedunculated (including sub-pedunculated lesions, Isp, and Ip) or non-pedunculated, which included sessile lesions (Is), flat polyps (II), and laterally spreading tumors. Histopathological analysis categorized the resected polyps as adenomatous (tubular, tubulovillous, villous, and carcinoma in situ) or non-adenomatous (serrated, hyperplastic, inflammatory, and mixed types).
Procedure-related variables: Procedure-related variables, including the endoscopic resection method, procedure duration, endoscopist experience, bowel preparation quality, and measures of hemostasis or prophylactic hemostasis, were assessed. Endoscopist experience was classified into attending staff with at least two years of experience or trainees with less than two years of experience. Subspecialty certification involves comprehensive training, including 2000 diagnostic and 100 therapeutic procedures over a two-year period, ensuring advanced competence. The choice of the endoscopic resection technique was at the practitioner’s discretion and was determined by polyp size and morphology. Cold forceps polypectomy or cold snare polypectomy was utilized for small polyps (< 10 mm), endoscopic mucosal resection was used for moderately sized polyps (10-20 mm), and endoscopic submucosal dissection was used for larger polyps (> 20 mm). Resection methods were classified according to electrocautery and submucosal injection use (cold forceps polypectomy and cold snare polypectomy vs endoscopic mucosal resection and endoscopic submucosal dissection). The total procedure time during colorectal polypectomy was calculated from scope insertion to completion, including the time to reach the cecum or terminal ileum and the withdrawal time from the cecum to rectum. Bowel preparation quality was graded into four categories (poor, adequate, good, and excellent) based on the Aronchick scale[26,27]. During instances of IPPB, hemostatic techniques, such as hemoclipping, electrocoagulation, or epinephrine injection, were utilized. When IPPB was absent, prophylactic hemostasis was considered at the clinician’s discretion for patients with potential bleeding risk factors, including large polyps (≥ 20 mm), pedunculated polyps with thick stalks, or patients receiving antithrombotic therapy[18]. However, considering the lack of clear consensus on the specific criteria for prophylactic hemostasis, our institutions generally followed these considerations without a standardized protocol, and practice patterns may have varied across endoscopists and time periods[18,28].
Outcomes
The main outcome of the study was to demonstrate the association between IPPB occurrence and DPPB risk and to identify risk factors among patients experiencing IPPB to determine those at high risk who may require enhanced post-polypectomy surveillance and preventive measures. IPPB was defined as bleeding persisting for 1-5 minutes during polypectomy despite irrigation[12,29]. DPPB was characterized by the occurrence of at least one episode of hematochezia necessitating endoscopic hemostasis that led to emergency intervention, hospitalization, or reintervention within 30 days of polypectomy[14].
Statistical analysis
Given the retrospective study design, no formal sample size calculation was performed; instead, all eligible patients during the study period were included to maximize statistical power. Continuous variables were expressed as the mean ± SD and compared using the independent two-sample t-test. Categorical variables were presented as frequencies and percentages and analyzed using the χ2 or Fisher’s exact test, as appropriate. The McNemar test was used to assess asymmetry in discordant IPPB-DPPB event patterns observed within the same individuals. For sensitivity analysis, the χ2 test was used to confirm the association between IPPB and DPPB.
Logistic regression analysis was used to identify risk factors for DPPB among patients with IPPB. Given the relatively small number of DPPB events among patients with IPPB, Firth’s penalized likelihood method was employed in the multivariable logistic regression analysis to reduce potential small-sample bias, including overfitting. Variables with a P < 0.2 in the univariate analysis were included in the multivariable logistic regression model. Potential multicollinearity among predictor variables was assessed based on conceptual and procedural relationships. Polyp size ≥ 10 mm (categorical) was excluded from the multivariable model because this variable represents a dichotomized form of the continuous polyp size variable already included in the model, and including both would introduce mathematical redundancy. Similarly, withdrawal time was excluded owing to its inherent relationship with total procedure time, of which it constitutes a substantial component. The remaining variables included in the final model (BMI, chronic kidney disease, polyp size, polyp number, non-adenomatous polyp, procedure time, and trainee endoscopist) represent clinically and statistically distinct characteristics without conceptual overlap. Furthermore, multicollinearity was strictly evaluated, and the variance inflation factor for all variables in the final model remained below 2, indicating a negligible level of collinearity. The results were presented as odds ratios (OR) with 95% confidence intervals (CIs). All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, United States), and data were visualized using R (version 4.5.1; R Project for Statistical Computing, Vienna, Austria). Statistical significance was defined as a two-sided P value of < 0.05.
RESULTS
Study flow and patient characteristics
Among the 21562 screened participants, 16684 patients met the inclusion criteria, encompassing a total of 41279 polyps. Of these patients, 933 (5.59%) exhibited IPPB involving 3784 polyps, whereas 15751 patients (94.41%) with 37545 polyps showed no signs of immediate bleeding. Among the patients who experienced IPPB, 35 of 933 individuals (3.75%) developed DPPB, whereas 246 of 15751 patients without IPPB (1.56%) developed DPPB (Figure 1). Table 1 shows a comparison of the baseline characteristics between patients who developed DPPB after IPPB (n = 35) and those who experienced IPPB alone (n = 898). Significant differences were observed in BMI (P = 0.004), polyp size (P = 0.002), number of polyps per patient (P = 0.037), and withdrawal time between the two groups (P = 0.031).
The analysis revealed a significant positive association between IPPB and DPPB (Figure 2). Among the 933 patients with IPPB, 35 (3.75%) subsequently developed DPPB; among the 15751 patients without IPPB, 246 (1.56%) developed DPPB (McNemar P value < 0.001). The DPPB proportion was significantly higher among patients with IPPB (3.75%, 95%CI: 2.58%-5.12%) than that among patients without IPPB (1.56%, 95%CI: 1.37%-1.77%), yielding a paired OR of 3.65 (95%CI: 3.17-4.20). Sensitivity analysis via the χ2 test confirmed a significant positive association between IPPB and DPPB (OR = 2.46, 95%CI: 1.71-3.52, P < 0.001), consistent with the McNemar test results.
Figure 2 Association analysis between immediate post-polypectomy bleeding and delayed post-polypectomy bleeding.
OR: Odds ratio; CI: Confidence interval; IPPB: Immediate post-polypectomy bleeding; DPPB: Delayed post-polypectomy bleeding.
Risk factors for DPPB in patients experiencing IPPB
In the univariate analysis of patients with IPPB, lower BMI, larger polyp size, higher number of polyps, and longer procedure and withdrawal times were associated with an increased risk of DPPB. Trainee-performed procedures showed a borderline association with DPPB. Multivariable logistic regression analysis, which included variables with P < 0.2 in the initial univariate analysis, identified trainee-performed procedures as the only independent risk factor significantly associated with DPPB (OR = 3.091, 95%CI: 1.037-9.219; P = 0.043) (Table 2).
Table 2 Risk factors for delayed post-polypectomy bleeding among immediate post-polypectomy bleeding patients.
In this large retrospective cohort study, we investigated the association between IPPB and DPPB and the risk factors for DPPB among patients with IPPB, with the aim of identifying high-risk patients who require enhanced post-polypectomy surveillance and preventive strategies. The major findings were as follows: (1) Patients with IPPB had a 3.6-fold higher incidence of DPPB than patients without IPPB; and (2) Among patients with IPPB, procedure performance by trainees was the only independent risk factor for DPPB (OR = 3.091, 95%CI: 1.037-9.219).
Previous studies reported that DPPB occurred in approximately 1.5%-1.7% of patients with IPPB, with reported ORs of 2.9-3.3, indicating that IPPB is a significant risk indicator for DPPB development[11,13,15]. However, previous studies had limitations, including small sample sizes and inadequate adjustment for confounding factors such as antiplatelet or anticoagulant use, polyp characteristics, comorbidities, laboratory findings, histopathological results, and endoscopic procedure details[11,13,15,21,30]. To overcome these limitations, we conducted a large-scale study comprising 41279 polyps in 16684 patients and included an extensive assessment of relevant variables. We demonstrated that patients experiencing IPPB had a significantly higher risk of DPPB, with procedure performance by trainees identified as an independent risk factor for DPPB among patients with IPPB. However, the precise mechanisms underlying the association between IPPB and DPPB remain unclear.
From a conceptual standpoint, IPPB may function as a risk indicator for subsequent DPPB. One plausible explanation is that IPPB reflects underlying vascular vulnerability or incomplete hemostasis at the polypectomy site; such conditions may predispose patients to delayed bleeding as the temporary wound eschar detaches and blood vessels are exposed before complete re-epithelialization[31]. Although IPPB occurrence itself is not predictable, the quality of hemostasis at the time of IPPB is modifiable and may partially mitigate subsequent DPPB risk. Notably, procedure performance by trainees was identified as the only independent risk factor for DPPB in patients with IPPB. Although case complexity and IPPB severity were not directly measured, this association remained significant after adjusting for procedure time, polyp size, and polyp number, which may serve as proxies for procedural complexity. Several previous studies have also reported less experienced endoscopists as an independent risk factor for DPPB[17,31,32]. These findings support trainee endoscopist status as an independent risk factor for DPPB and suggest the importance of adequate supervision and training during polypectomy procedures, particularly for patients who experience IPPB[33]. Several variables including BMI, polyp size, polyp number, and procedure time were significant in univariate analysis but not in the multivariable model. This may reflect confounding relationships or overlapping effects among the multiple factors associated with PPB.
Our findings have important clinical implications. IPPB serves as an indicator identifying patients at elevated DPPB risk. Patients experiencing IPPB should be recognized as a high-risk group warranting closer surveillance and enhanced post-procedure vigilance. Based on our findings, we suggest the following considerations for clinical practice. First, meticulous inspection and thorough irrigation of the resection site, extended monitoring for IPPB detection, and application of combination hemostatic techniques may help minimize subsequent DPPB risk. Although current guidelines do not recommend routine clip closure[34], prophylactic clip placement may be considered in select cases, particularly when trainees perform a polypectomy. Second, extra caution is warranted when resuming antithrombotic therapy in patients with IPPB, particularly after procedures performed by trainees, with decisions made in close consultation with the prescribing physician. Third, patients could be provided with comprehensive information and detailed explanations of bleeding symptoms and preventive measures to ensure their safety. Finally, our results suggest the potential value of increased supervision during trainee-performed polypectomies, particularly when IPPB occurs, along with focused training in effective immediate hemostasis techniques and a lower threshold for promptly involving attending physicians[18,28,35]. However, these recommendations are based on observational associations and require prospective validation prior to their implementation as standard practice.
This study had some limitations. First, despite accounting for numerous covariates, residual confounding factors may persist owing to unmeasured or inadequately measured factors, such as the precise timing of antithrombotic resumption, which could influence the risk of DPPB. However, current guidelines do not provide a standardized protocol regarding exact resumption timing[22-24], making standardized measurement inherently difficult. In this study, we adjusted for established risk factors identified in previous studies and incorporated all measurable variables available in our dataset. Second, the relatively small number of DPPB events among patients with IPPB (n = 35) limited the statistical power of the multivariable analysis. Nevertheless, the primary analysis comparing DPPB rates between patients with and without IPPB had sufficient power owing to the large overall sample size. Moreover, the significant association observed for trainee-performed procedures despite the limited number of events suggests a robust effect. Although the number of DPPB events among patients with IPPB was limited, we addressed the potential risk of overfitting by applying Firth’s penalized likelihood method in the multivariable analysis. In addition, sensitivity analyses using alternative analytical approaches yielded consistent results, supporting the robustness of our findings. Third, the definition of IPPB as bleeding persisting for 1-5 minutes despite irrigation relies on operator judgment, which may introduce inter-observer variability. Additionally, variability in the application of hemostatic techniques across endoscopists may have introduced procedural inconsistencies. However, international consensus on the definition of intraprocedural bleeding remains incomplete[11,18,21], and our time-based definition is comparable to those employed in prior studies[18]. Fourth, owing to the retrospective nature of this cohort study, a definitive causal relationship between IPPB and DPPB could not be established. Nonetheless, given the rare and unpredictable occurrence of IPPB, conducting a large prospective study would be challenging. Despite the large sample size and concerted efforts to minimize bias, our findings indicate an association rather than causality and require prospective validation before clinical implementation. Finally, the study was conducted at two tertiary referral hospitals in Korea, with a relatively high proportion of high-risk patients and procedures performed by trainees, which may limit its generalizability to other settings, countries, or populations. Future prospective multicenter studies or randomized controlled trials with larger event numbers are warranted to validate our findings and address these limitations.
CONCLUSION
This large retrospective cohort study demonstrated a significant positive association between IPPB and subsequent DPPB risk, with patients who experienced IPPB experiencing a 3.6-fold higher incidence of DPPB. We suggest that, for cases of IPPB following colonoscopic polypectomies, particularly those performed by trainees, several preventive strategies should be considered to reduce the risk of DPPB.
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Creativity or innovation: Grade A, Grade B, Grade B, Grade B, Grade C
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P-Reviewer: Chen YX, PhD, Postdoctoral Fellow, China; Khan A, PhD, Postdoctoral Fellow, Pakistan; Zhang WY, MD, Assistant Professor, China S-Editor: Fan M L-Editor: A P-Editor: Zhang L
