Episode four teaches the post-polypectomy adverse event set through mechanism, because each event has a distinct anatomic or thermal correlate that determines the next move. Immediate bleeding is treated at the visible vessel while delayed bleeding returns for endoscopic hemostasis on the still-recognizable scar, and the prophylactic-clip decision turns on proximal location and antithrombotic risk rather than reflex. Perforation forces a closure decision driven by defect age and size, while post-polypectomy electrocoagulation syndrome mimics perforation but lacks free air and resolves on bowel rest. The unifying frame is that the recognition cue tells you the mechanism and the mechanism tells you the response, so hematochezia, free air, focal peritonitis without free air, and left shoulder pain are not interchangeable. Topics covered Immediate versus delayed post-polypectomy bleeding Endoscopic hemostasis modalities The prophylactic-clip decision Perforation rates and recognition Endoscopic closure versus surgery Post-polypectomy electrocoagulation syndrome Splenic injury and the Kehr sign Key decisions Immediate bleeding at the polypectomy site is managed at the visible vessel with hemoclips, snare-tip or forceps coagulation, or epinephrine paired with a definitive modality, while delayed bleeding at one to fourteen days returns for repeat colonoscopy with hemostasis on the recognizable scar. Prophylactic clip closure of large proximal EMR defects reduces delayed bleeding with a number needed to treat around ten in patients on antithrombotics or with proximal lesions over twenty millimeters, but routine closure of small left-sided defects off antithrombotics is not standard. A fresh perforation under two centimeters recognized during the procedure can be closed endoscopically with through-the-scope clips, over-the-scope clips, or suturing with success above ninety percent. Larger defects, older perforations, established peritoneal contamination, or poor closure positions go to the operating room. Post-polypectomy electrocoagulation syndrome presents twenty-four to seventy-two hours after hot snare with fever and focal peritonitis but no free air on imaging, and management is bowel rest, intravenous antibiotics, and observation rather than surgery. Post-colonoscopy peritoneal signs, fever, leukocytosis, and free air on imaging are perforation until proven otherwise, worked up with cross-sectional imaging and surgical consultation. Splenic injury from splenocolic-ligament traction presents with left upper quadrant pain radiating to the shoulder as the Kehr sign, and is managed from observation through embolization to splenectomy by hemodynamic stability. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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