Article, Surgery

Splenic rupture after colonoscopy

Case Report

splenic rupture after colonoscopy

Abstract

In the Emergency Department, splenic rupture is commonly associated with blunt and penetrating abdominal trauma. A case of splenic rupture as a result of a routine colonoscopy is presented, followed by a literature review of this unusual complication. Emergency physicians should have a high index of suspicion for this complication when evaluating postcolonoscopy patients.

Traumatic rupture of the spleen is an injury frequently encountered in the Emergency Department (ED). The spleen is the most commonly injured organ in cases of blunt abdominal trauma; and in cases of penetrating abdominal trauma, the incidence of splenic injury ranges from 2% (Stab wounds) to 10% (gunshot wounds).

An unusual cause for splenic rupture is that resulting as a complication of routine colonoscopy. Of the known complications from colonoscopy, hemorrhage and per- foration are the most common, with rates being higher in patients undergoing biopsy or polypectomy [1]. Rupture of the spleen after colonoscopy, however, is an exceedingly uncommon entity, with less than 40 cases reported in the general medical literature and none reported in the emergency medicine literature [2]. This report describes a case of splenic rupture after diagnostic colonoscopy, followed by a brief literature review.

A 50-year-old woman presented to the ED for evaluation of abdominal pain 34 hours after having undergone outpatient colonoscopy. The colonoscopy was performed to evaluate the etiology of hematochezia and revealed internal hemorrhoids only; no biopsies or polypectomies were taken, and the procedure was described as uncomplicated.

Several hours after the colonoscopy, the patient reported mild discomfort in the left upper quadrant of the abdomen, which she attributed to gas pain. This discomfort persisted and progressively worsened over the course of the day. She was able to go to work the following day; but at dinnertime, she experienced a marked increase in pain, which had become more diffuse to include the entire left abdomen with radiation to the left anterior chest and shoulder. The pain did worsen with deep inspiration, and she felt bloated. She

denied dizziness, diaphoresis, fever, chills, nausea, diarrhea, or urinary symptoms. She reported having been in her usual state of good health before colonoscopy.

Her medical history was remarkable for chronic obstruc- tive pulmonary disease and hyperlipidemia; her surgical history included tonsillectomy and 2 previous Cesarean deliveries. Her medications were Lipitor and Advair.

Initial examination showed a temperature of 36.7?C (98.0?F), heart rate of 95 beats per minute, respirations of 20, blood pressure of 120/91 mm Hg, and a reported pain score of 8. She was alert and appeared somewhat uncomfortable. Her abdomen was slightly rounded, had decreased bowel sounds, and was tender to palpation in the left upper quadrant with guarding. No periumbilical or flank ecchymosis was noted. Kehr sign was present and accentuated with the patient in a supine position. There was no tenderness to percussion of the left costovertebral angle, and the lungs were clear to auscultation without chest wall tenderness. A rectal examination was not performed. Laboratory data were remarkable for hemoglobin of 12.1 g/dL, white blood cell count of 8800/mm3, and platelet count of 344000/mm3. Coagulation studies, routine chemistries, and a 12-lead electrocardiogram were normal. A computed tomographic (CT) scan of the abdomen and pelvis revealed a 4 x 10-cm perisplenic hematoma (Fig. 1) with approximately 5 cm of layered blood in the pelvis and right pericolic gutter. The

Fig. 1 Computed tomographic scan of the abdomen and pelvis revealing a 4 x 10-cm perisplenic hematoma (arrow).

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117.e2 Case Report

Fig. 2 Anatomic depiction of the the splenocolic ligament.

patient had an episode of transient hypotension, which responded favorably to an intravenous fluid bolus. After Surgical consultation, she was admitted to the intensive care unit for Close monitoring; operative intervention was not required. She was observed in the hospital for a total of nearly 48 hours, remained hemodynamically stable with gradual improvement of her pain, did not require blood transfusion, and was discharged home.

A second CT scan 1 month later showed interval organization of a subcapsular hematoma and resolution of the intraperitoneal blood. At 4 months postcolonoscopy, the patient reported during a follow-up phone call that she remained asymptomatic; another CT scan around that same time revealed a small resolving subcapsular splenic fluid collection.

An estimated 14.2 million colonoscopies are performed in the United States annually, with a continued increase expected as the general population ages [3]. Complications from colonoscopy are unusual; in a retrospective study of more than 16000 adults undergoing colonoscopy, the rate of complications was found to be 5.0 per 1000 colonoscopies, with a higher incidence in patients who had biopsy or polypectomy during their procedures [1]. The 2 most common complications are perforations (0.9 per 1000 colonoscopies) and bleeding from biopsy and polypectomy sites (4.8 per 1000 colonoscopies). Interestingly, there were no reported cases of splenic rupture in this large cohort of patients. Other uncommon complications of colonoscopy include pneumothorax, pneumomediastinum, mesenteric tears, volvulus, intramural hematomas, infection, retroper- itoneal abscess, appendicitis, and postpolypectomy coagula- tion syndrome [4,5].

Traumatic rupture of the spleen during colonoscopy is an unusual occurrence and has a very low incidence rate; 2 large analytical series of colonoscopies describe no splenic injuries [1,5], whereas other published articles estimated an incidence as high as 1 per 6000 colonoscopies [2,6].) Several mechanisms have been postulated to describe this

complication of colonoscopy. The most frequently postu- lated mechanism for splenic injury involves avulsion of the splenic capsule from excessive traction by the colonoscope on the splenocolic ligament (Fig. 2). It is hypothesized that colonoscopic negotiation of a tightly angled splenic flexure is the precipitating maneuver that results in splenic injury [7-14]. Alternatively, the spleen may sustain a direct blow from the colonoscope during difficult manipulation through the splenic flexure [7]. Another postulated mechan- ism is that dense adhesions that formed between the colon and spleen, as may occur in cases of patients with previous laparotomies, may promote excessive traction during colonoscopy, causing a capsular tear of the spleen [8]. Certain techniques used during colonoscopy to aid in the passage of the instrument through the colon, such as externally applied pressure and certain operator maneuvers, have also been postulated as causes for splenic injury, causing either direct splenic trauma or excessive torsion of the splenocolic ligament [11,14].

Risk factors for this phenomenon include conditions that may predispose to splenocolic adhesions such as previous laparotomy, pancreatitis, inflammatory bowel disease, or multiple previous colonoscopies [7,15]. Conditions that cause splenomegaly or underlying splenic disease, such as infections with malaria, typhoid fever, infectious mono- nucleosis, or leukemic infiltration of the spleen, have been postulated as additional risk factors [16]. Technical difficulty or inexperience by the physician in performing the colono- scopy has been cited as predisposing to procedural splenic injury [7], while coagulopathic patients are also at risk for rupture and hemorrhage [17].

The first published case of splenic injury during colonoscopy was described in 1974 by Wherry and Zehner [18]. A review of 5000 colonoscopies in 1983 found no splenic injuries [5]. Two subsequent reports in 1991 and 1994, with a combined total of more than 36000 colonos- copies, reported only 1 case of splenic injury [19,20]. Most published studies of colonoscopic splenic rupture are case reports; there exist nearly 40 reported cases of colonoscopic splenic trauma in the medical literature [9], including this report. Analysis of these cases reveals that most of these patients present within 24 hours of their colonoscopies (with a range of 2 hours to 10 days), with most complaining of abdominal pain, although nearly half of these patients also presented with evidence of shock or hemorrhage. Kehr sign-referred left shoulder pain due to diaphragmatic irritation-is reported to occur in 90% of cases of splenic rupture [21]; unfortunately, it is also reportedly present in 50% of patients who have undergone uncomplicated colonoscopies, thereby limiting its usefulness [14]. In the pre-CT era, most cases were detected at the time of surgery; more recently, cases have been detected by noninvasive methods such as CT scan or ultrasound [4,7-11,14,15,22]. A recent review of 18 case reports of colonoscopic splenic rupture found that most patients presented with anemia (68%) or leukocytosis (87%); half of the patients in this

Case Report 117.e3

review were diagnosed by CT scan, whereas 2 cases were detected by bedside ultrasound [10,22]. Of 38 reported cases of colonoscopic splenic injury, 13 (38%) have had risk factors predisposing to intraabdominal adhesions; and only 6 (16%) reported technical difficulties during the procedure [9]. Overall, 27% of patients who have sustained colono- scopic splenic rupture (including this present report) were treated nonoperatively [9]. One case report describes a failed ultrasound-guided percutaneous drainage of a colonoscopic splenic hematoma that eventually necessitated splenectomy [9]. Another recent review of 27 reported cases of colono- scopic splenic rupture noted 2 deaths, one of which was due to hemorrhagic shock before the diagnosis of splenic rupture was made (ruptured spleen discovered at autopsy) [2].

Although most postcolonoscopy patients will have no complications, the emergency physician must be aware of the

2 most common complications of colonoscopy, namely, perforation and hemorrhage. However, a postcolonoscopy patient who presents with persistent abdominal pain, anemia, and signs and symptoms of Hemodynamic compromise should also raise suspicion for splenic rupture. abdominal CT scanning remains the most commonly used modality to detect this unusual condition, although bedside ultrasono- graphy may detect hemoperitoneum more rapidly, especially in unstable patients [23]. Awareness of this unusual complication from colonoscopy coupled with a high index of suspicion is necessary to make a Timely diagnosis.

Carlos G. Duarte MD Department of Emergency Medicine Delnor-Community Hospital Geneva, IL 60134, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2007.07.020

References

  1. Levin TR, Zhao W, Conell C, Seeff LC, et al. Complications of colonoscopy in an integrated Health care delivery system. Ann Intern Med 2006;145:880-6.
  2. Tsoraides SS, Gupta SK, Estes NC. Splenic rupture after colonoscopy: case report and literature review. J Trauma 2007;62:255-7.
  3. Seeff LC, Richards TB, Shapiro JA, et al. How many endoscopies are performed for Colorectal cancer screening? Results from CDC’s survey of endoscopic capacity. Gastroenterology 2004;127(6):1670-7.
  4. Meyers MA, Ghahremani GG. Complications of fiberoptic endoscopy

II. Colonoscopy. Radiology 1975;115(2):301-7.

  1. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 500 diagnostic or therapeutic colonoscopies. Gut 1983;24:376-83.
  2. Goitein D, Goitein O, Pikarski A. Splenic rupture after colonoscopy. IMAJ 2004;6:61-2.
  3. Tse CCW, Chung KM, Hwang JST. Splenic injury following colonoscopy. Hong Kong Med J 1999;5:202-3.
  4. Levin E, Wetzel LH. Splenic trauma during colonoscopy. AJR Am J Roentgenol 1998;149:939-40.
  5. Shatz DV, Rivas LA, Doherty JC. management options of colono- scopic splenic injury. J Soc Laparoendosc Surg 2006;10(2):239-43.
  6. Volchok J, Cohn M. Rare complications following colonoscopy: case reports of splenic rupture and appendicitis. J Soc Laparoendosc Surg 2006;10(1):114-6.
  7. Taylor FC, Frankl HD, Riemer KD. Late presentation of splenic trauma after routine colonoscopy. Am J Gastroenterol 1989;84(4): 442-3.
  8. Espinal EA, Hoak T, Porter JA, Slezak FA. Splenic rupture from colonoscopy. Surg Endosc 1977;11:71-3.
  9. Lekas BJ. Splenic hematoma as a complication of colonoscopy. J Am Geriatr Soc 2004;52(2):320-1.
  10. Janes SE, Cowan IA, Dijkstra B. A life threatening complication after colonoscopy. Basic Mus J 2005;330:889-90.
  11. Ahmed A, Eller P, Schiffman F. Splenic rupture: an unusual complication of colonoscopy. Am J Gastroenterol 1997;92:1201-3.
  12. Coughlin F, Aanning HL. Delayed presentation of splenic trauma following colonoscopy. S D J Med 1997;50(9):325-6.
  13. Gallo D, Tebrock C, Rivera D. Intramural cecal hematoma: an unusual complication of colonoscopy. Gastroint Endosc 2003;57(2):254-7.
  14. Wherry DC, Zehner H. Colonoscopy-fiberoptic endoscopic approach to the colon and polypectomy. Med Ann D C 1974;43: 189-92.
  15. Ong E, Bohmler U, Wurbs D. Splenic injury as a complication of endoscopy: two case reports and a literature review. Endoscopy 1991;23:302-4.
  16. Jentschura D, Raute M, Winter J, Henkel T, Kraus M, Manegold BC. Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis. Surg Endosc 1994;8:672-6.
  17. DeGowin RL, Brown DD. Abdomen: gastrointestinal and hepatobili- ary systems. De Gowin’s diagnostic examination. 7th ed. New York (NY): McGraw-Hill; 2000. p. 574.
  18. Reissman P, Durst AL. Splenic hematoma: a rare complication of colonoscopy. Surg Endosc 1998;12:154-5.
  19. American College of Surgeons. Abdominal trauma. Advanced trauma life support for doctors. Chicago (Ill): American College of Surgeons; 1997. p. 157-75.