A 58-year-old man undergoes colonoscopy for screening. A 15 mm pedunculated adenomatous polyp with a distinct stalk is identified in the sigmoid colon. The polyp head is 18 mm in diameter and the stalk is 4 mm thick. The procedure shown at **D** (Endoscopic Snare Polypectomy) is planned. Which of the following management strategies is most appropriate to reduce the risk of post-polypectomy bleeding in this case?

Explanation

## Why Option B is correct For pedunculated adenomas >10 mm with a polyp head >2 cm or stalk ≥5 mm, the clinical anchor dictates prophylactic hemostasis to prevent post-polypectomy bleeding (which occurs in 1–2% immediate, up to 6% delayed, and up to 14 days delayed). Although this patient's stalk is 4 mm (just below the 5 mm threshold), the polyp head is 18 mm (approaching 2 cm), placing it in the higher-risk category. Hot snare polypectomy is the standard technique for pedunculated polyps, but it must be combined with pre-injection of saline-epinephrine at the stalk base and prophylactic placement of endoloop or hemostatic clips to seal the stalk and prevent hemorrhage (Harrison 21e Ch 80; USMSTF 2020). ## Why each distractor is wrong - **Option A**: Hot snare alone without prophylactic measures is inadequate for a large pedunculated polyp (head 18 mm). The anchor explicitly states prophylactic closure is indicated when head >2 cm OR stalk >5 mm; this polyp meets the size criterion for head and approaches the stalk threshold, warranting prophylaxis. - **Option C**: Cold snare is reserved for small polyps (≤9 mm). This 15 mm pedunculated polyp requires hot snare technique. Thermal coagulation alone without mechanical closure (endoloop/clips) is insufficient for stalk hemostasis in large pedunculated lesions. - **Option D**: EMR with piecemeal resection is the technique for large sessile or laterally spreading tumors (≥20 mm). This polyp is pedunculated with a distinct stalk, making it ideal for en-bloc hot snare resection, not piecemeal EMR. **High-Yield:** Pedunculated adenomas >10 mm with head >2 cm or stalk >5 mm require prophylactic hemostasis (saline-epinephrine injection + endoloop or clips) to prevent post-polypectomy bleeding. [cite: Harrison 21e Ch 80; USMSTF 2020 Surveillance Guidelines]