The Polyp That Won't Stop Bleeding: Endoscopic Hemostasis in the Setting of Severe Thrombocytopenia

Introduction: Management of acute leukemia often includes anticipating severe cytopenias. Severe thrombocytopenia can lead to many complications, including gastrointestinal (GI) bleeding. Further, platelets below 20,000 make justifying surgical and or endoscopic procedures difficult in the setting of stable bleeding. In light of ongoing bleeding and the need for multiple blood products to support hemodynamics, the clinician may raise the question of whether it is an absolute contraindication to safely performing endoscopic procedures. Case Description/Methods: This case reports an example of a patient with severe thrombocytopenia in the setting of acute myeloid leukemia who presented with hematochezia. Her platelet count was 10,000/mL on arrival. CT-A was ultimately done and revealed a bleeding rectal polyp. In total, she received 13 units of platelets, 8 units of packed red blood cells, and 2 units of cryoprecipitate while attempting to raise her counts high enough for intervention or allow for spontaneous resolution. Her counts never recovered and it was decided to attempt colonoscopy at a platelet count of 13,000/mL. Hemostasis was successfully achieved using endoclips and epinephrine injection. (Figure) Discussion: Patients, especially those with hematologic malignancies, may present with severe thrombocytopenias and gastrointestinal bleeding that requires hemostasis. There are no clear guidelines as to a safe platelet level to perform endoscopy while minimizing bleed risk. However, this case presents successful hemostasis in a patient with platelets less than 20,000/mL refractory to transfusion. Future research should be done to better elucidate what platelet count is safe for endoscopic procedures.Figure 1.: Colonoscopy images a) 3 cm polyp in distal sigmoid with sigmata of recent bleed, b) polyp stalk, c) and d) two clips applied to stalk, e) endoloop applied, f) additional 2 clips below loop.