S5213 To Bleed or Not to Bleed: Removal of a Large Rectal Polyp in a Jehovah’s Witness

Introduction: Colonic polyps are abnormal growths in the gastrointestinal tract, categorized into neoplastic, hyperplastic, hamartomatous, and inflammatory types. While many are benign, neoplastic polyps can progress to malignancy if not detected and removed early. Polyps larger than 5 mm carry a higher risk of malignancy and are often associated with gastrointestinal bleeding, anemia, and abdominal pain. In rare cases, they can cause bowel obstruction or hemorrhagic shock. Endoscopic removal is preferred but may be challenging depending on polyp size and location. For patients who decline blood transfusions, such as Jehovah’s Witnesses, prevention of complications like acute blood loss is especially critical. Case Description: A 74-year-old man with hyperlipidemia and a known rectal polyp was referred for treatment. He identified as a Jehovah’s Witness and refused blood products. A repeat sigmoidoscopy and endoscopic ultrasound ruled out lymph node involvement and mucosal thickening. Endoscopy revealed a 10-15 cm laterally spreading rectal tumor occupying over 75% of the lumen. The lesion was classified as Paris IS + IIB and Kudo IIIL/V. Endoscopic submucosal dissection (ESD) was performed successfully using electrocautery, and the lesion was removed en bloc, measuring 9.5 × 5.5 × 0.3 cm. The mucosal defect, covering 75% of the lumen, was treated with synthetic peptide gel and hemoclips. Final pathology showed multiple tubular adenomas with focal high-grade dysplasia and negative margins. Hemoglobin remained stable throughout hospitalization. Discussion: Managing large polyps in patients refusing blood products presents unique challenges. While surgical resection remains common, it carries increased risk of blood loss and complications. ESD offers a less invasive alternative with lower complication rates. Literature shows that Jehovah’s Witnesses undergoing endoscopic procedures do not experience increased mortality or length of stay. This case highlights the effectiveness and safety of ESD for large polyp removal in patients with religious constraints. Ongoing research and development of tailored, bloodless management protocols are essential to optimize outcomes in this population.