Ezhuthachan College of Pharmaceutical Sciences
Peutz-Jeghers syndrome (PJS) is a rare condition that runs in families and causes many growths in the digestive tract. It can lead to problems like bleeding, anemia, and a condition where part of the intestine folds into itself. After removing these growths, there's a risk of bleeding, especially if the intestines have been changed due to past surgeries. We describe a case of a 25-year-old man who has PJS and previously had part of his colon removed. He came in because he was bleeding from the rectum after a procedure to remove a growth. During a colonoscopy, doctors found active bleeding at the site where the intestine was reconnected after the surgery. They used a special tool to stop the bleeding, which worked. This case shows how important it is to keep a close eye on people with PJS, act quickly if there's a problem, and watch for any issues after procedures.
Peutz-Jeghers syndrome (PJS) is a rare inherited condition passed down rough families, where people develop many non-cancerous growths called hamartomatous polyps in heir digestivesystem.[1,3] These polyps can appear in different parts of the gastrointestinal tract, and people with PJS also have darker spots on their skin and mouth. This condition increases the risk of several healthproblems throughout life, such as internal bleeding,anemia, blockages in part of the small intestine, intussusception and cancer in various organs. Because of this, regular medical check-ups and early treatments are very important.[1,3,5].Endoscopic procedures, like using a special scope to remove polyps, are a common way to treat the small bowel polyps in PJS. These techniques aim to reduce the number of polyps and prevent serious issues like blockages and intussusception. However, one important side effect of these procedures is bleeding after the polyps are removed. This can happen due to factors related to the polyps themselves or the patient’s overallhealth.[6,7,8].In general, factors that increase the chances of bleeding after polyp
removal include the size and shape of the polyp, as well as the type of tissue it is made of. In cases involving hamartomatous polyps, which are common in PJS, there is a higher chance of bleeding. While large studies on polyp removal in the general population give varying results, studiesfocusing on PJS patients show that the risk of bleeding is particularly high.[6,9] In PJS, although there are not many large studies on bleeding after removal, available research showsthat bleeding is a significant concern during procedures. Some techniques used during endoscopic polypectomy, such as ischemic polypectomy, which usesclamps or clips, not only help remove the polyps but also reduce the risk of bleeding and othercomplications. In younger patients with PJS, traditional endoscopic removal of polyps is associatedwith a measurable chance of bleeding, highlighting the need for careful technique and attentionduring the procedure. Also, some rare reports suggest that patients with PJS can have issues with blood clotting, making them more prone to bleeding after surgery.[6,10] In gastrointestinal surgeries, the areas where two parts of the intestine were joined together (called anastomotic sites) can be more vulnerable to bleeding, especially if they have been operated on before. For people with PJS who have had previous surgeries, endoscopic procedures near these areas may carry greater risks of bleeding. However, there isn't much detailed information on these risks in the medical literature.[7,8] The combination of changes in the body's structure, previous scarring, and the nature of the polypsmeans that careful planning, proper techniques to stop bleeding before and during surgery, and closemonitoring after the procedure are necessary to manage any possible complications.[10,4,9]
CASE REPORT:
A 25-year-old male presented with multiple episodes of bleeding per rectum. There was no associated abdominal pain, distension, vomiting, or fever. He was a known case of Peutz–Jeghers syndrome with a significant past surgical history of right hemicolectomy in 2018 performed for intussusception. On Clinical Examination , the patient was conscious and oriented, moderately built, with clinical pallor. Vital signs were stable (pulse 82/min, blood pressure 120/80 mmHg, SpO? 98% on room air). Abdominal examination was unremarkable with no tenderness, organomegaly, or distension. Systemic examination was otherwise within normal limits. Laboratory Findings showed Hemoglobin levels were reduced ( 8.7–8.3 g/dL), consistent with anemia secondary to gastrointestinal blood loss. Other routine investigations were within acceptable limits. The patient underwent colonoscopy, which revealed: Evidence of oozing hemorrhage from a post-polypectomy site at the ileocolonic anastomosis, a previously resected pedunculated polyp at the anastomotic site, Rectal polypectomy site appeared clean. Rest of the colon including transverse, descending, sigmoid colon and rectum appeared normal.
Management : Endoscopic hemostasis was achieved by application of three hemoclips at the bleeding anastomotic site, following which complete hemostasis was noted. The procedure was uneventful. The patient was admitted for observation, managed conservatively, and remained hemodynamically stable with no further episodes of bleeding. He was discharged with appropriate medications and advised close follow-up, including review with histopathology reports.
DISCUSSION
Peutz–Jeghers syndrome (PJS) is a rare inherited condition characterized by mucocutaneous pigmentation and the development of multiple hamartomatous polyps throughout the gastrointestinal tract. First described by Jan Peutz and later expanded by Harold Jeghers, the syndrome is well known for its association with complications such as intussusception, gastrointestinal bleeding, and an increased risk of malignancy. Bleeding per rectum in patients with PJS is most often related to polyp ulceration or mechanical trauma. However, delayed bleeding following polypectomy—especially from an anastomotic site—is relatively uncommon and not widely reported. In the present case, the patient developed bleeding from a previous polypectomy site at the ileocolonic anastomosis, making it a noteworthy and less frequently documented presentation.
Previous studies, particularly by Giardiello FM et al., have shown that small intestinal polyps are the most frequent source of complications in PJS, with intussusception being a common reason for surgical intervention. This is consistent with our patient’s history of right hemicolectomy. At the same time, van Lier MG et al. highlighted the long-term risks associated with repeated surgeries, including the development of short bowel syndrome, thereby emphasizing the importance of minimizing surgical interventions whenever possible. Post-polypectomy bleeding itself is a known complication in general endoscopic practice. As noted by Waye JD, delayed bleeding can occur in a small percentage of cases, usually due to sloughing of the coagulum or incomplete initial hemostasis. However, there is limited literature specifically addressing this complication in patients with PJS. In this context, our case reflects the observations made by Latchford AR et al., who pointed out that patients with PJS often undergo multiple endoscopic procedures over time and are therefore at an increased cumulative risk of procedure-related complications.The management approach in our patient further highlights the effectiveness of endoscopic therapy. Hemostasis was successfully achieved using hemoclips, which are widely regarded as a safe and reliable option. Studies by Jensen DM et al. support the use of mechanical clipping as it provides prompt and sustained control of bleeding in non-variceal gastrointestinal hemorrhage. Avoiding repeat surgery in our patient was particularly important given his prior surgical history. Additionally, the absence of other active lesions in the colon and the presence of a clean rectal polypectomy site suggest that the bleeding was localized, rather than diffuse. This observation aligns with the findings of Beggs AD et al., who emphasized that surveillance and intervention in PJS should be focused on high-risk or symptomatic lesions rather than adopting a more extensive approach.Compared to previously reported cases, our patient’s presentation stands out due to the delayed onset of bleeding from an ileocolonic anastomotic site, the background of prior bowel surgery adding anatomical complexity, and the successful management using endoscopic techniques alone without recurrence. Overall, this case underlines the growing role of therapeutic endoscopy in the management of PJS-related complications. It also reinforces the current preference for minimally invasive strategies, which can effectively control symptoms while reducing the need for repeated surgical interventions.
CONCLUSION
Peutz–Jeghers syndrome is a lifelong condition that often brings patients back for repeated evaluations and interventions due to its recurrent gastrointestinal complications. This case highlights an unusual but important presentation of delayed bleeding from a post-polypectomy site at an ileocolonic anastomosis. It reminds clinicians to consider procedure-related bleeding as a possible cause when patients with PJS present with rectal bleeding, particularly in those with a prior surgical history. Early endoscopic assessment is key, as it not only helps in identifying the exact source but also allows for prompt treatment.
In our patient, endoscopic hemoclip application provided effective and lasting control of bleeding, avoiding the need for further surgery. This reinforces the value of minimally invasive endoscopic techniques in managing such complications. Ongoing surveillance and timely, targeted interventions remain essential to improve outcomes and reduce the overall treatment burden in patients with PJS.
REFERENCES
Pavithra Biju Bijumon, Grace Raju, Shaiju Dharan, Post-Polypectomy Bleeding at Anastomotic Site in a Patient with Peutz–Jeghers Syndrome: A Case Report, Int. J. of Pharm. Sci., 2026, Vol 4, Issue 4, 3900-3904, https://doi.org/10.5281/zenodo.19706729
10.5281/zenodo.19706729
