Article, Gastroenterology

Splenic rupture after colonoscopy

Case Report

splenic rupture after colonoscopy

Abstract

Colonoscopy is currently the gold standard diagnostic and therapeutic procedure for rectum and colon pathologies. The rate of complications is low; the most frequent are perforation and intraluminal bleeding. The occurrence of splenic rupture is uncommon after colonoscopy. Although potentially fatal, it remains rarely considered in the differential diagnosis of post-colonoscopic abdominal pain. We report a case of splenic rupture diagnosed 48 hours after colonoscopy, treated with urgent splenectomy.

An outpatient colonoscopy was performed in a 68-year- old woman to investigate nonspecific chronic abdominal pain, associated to a 10-kg weight loss over the previous 6 months. The medical history was significant for chronic obstructive pulmonary disease, dyslipidemia, and no surgical history. The procedure was uneventful until 90 cm from the anal margin, when the patient developed sudden acute left upper quadrant pain. The colonoscopy was stopped and the patient was sent to a low-volume center where a none- nhanced abdominal computed tomographic (CT) scan was performed. It ruled out the presence of free intraabdominal air or fluid (Fig. 1), but demonstrated an image of chronic pancreatitis together with a dilated duct and neighboring enlarged lymph nodes. The spleen was described as normal. Laboratory tests were noncontributive, except increased Pancreatic enzymes (doubled compared to standard).

Guided by these results, the experienced emergency physician considered a chronic pancreatitis as the first differential diagnosis. After 24 hours of surveillance, and, as the pain was under control with Oral medication, and laboratory tests stable, he sent the patient to her general practitioner for further investigations and management. The next day, while she was going out of her doctor’s office, the patient experienced a marked increase level of abdominal pain with dizziness, and she subsequently passed out.

On admission in our emergency department, she was alert but pale and in shock (blood pressure, 55/40; heart rate, 40/min [1]; respiratory rate, of 20/min). Her abdomen was tense, tender in the left upper quadrant with guarding and rebound tenderness. Laboratory tests demonstrated

anemia (hemoglobin level, 11.0 g/dL) and moderately increased lipase, Gamma-glutamyltransferase, and Alanine transaminase. Coagulation tests were within normal ranges. An enhanced CT scan revealed the presence of an active bleeding from the spleen with subcapsular hematoma and free intraabdominal fluid (Fig. 2). In addition, this test brought to light a nonenhancing mass of the pancreatic neck (previously identified as a localized inflammation on the

nonenhanced CT scan) (Fig. 3).

After adequate resuscitation, an emergency splenectomy was performed with lymph node sampling. The postoperative course was uneventful, but the final histological result of the nodes came back positive for a well-differentiated adenocar- cinoma. The patient has subsequently undergone palliative chemotherapy because of the unresectable nature of the tumor. The present case illustrates three relevant points, including the rare risk of splenic rupture after colonoscopy, the limited diagnostic value of nonenhanced CT scan, and

the association with a pancreatic neoplasm.

Splenic injury is a rare complication after colonoscopy; less than 60 cases have been reported in the literature so far [2]. The main recognized mechanisms of injury are excessive traction on the splenocolic ligament, inducing a tear of the capsule, and looping of the endoscope [2]. Conditions associated to a decreased mobility between the spleen and the colon are considered Predisposing factors, including

Fig. 1 Nonenhanced CT scan, 3 hours after colonoscopy.

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241.e2 Case Report

In the present case, the imaging has been performed early after the colonoscopy and without intravenous contrast, thus not allowing the detection of the bleeding. The imaging modality of choice should therefore be enhanced CT scan, to look for intraabdominal Free air or fluid and a possible extravasation of contrast.

Fig. 2 CT scan with intravenous contrast of the abdomen, demonstrating an active bleeding from the spleen with subcapsular hematoma, 48 hours after colonoscopy.

Fig. 3 CT scan with intravenous contrast showing pancreatic neck mass.

splenomegaly, inflammatory bowel disease, pancreatitis, and intraabdominal postsurgical adhesions [3]. In this case, the presence of a pancreatic mass with a neighboring pancreatitis could be seen as a possible risk factor. The clinical presentation was also remarkable for acute left upper quadrant pain, which should be identified as a symptom of possible splenic rupture, leading to subsequent relevant investigations.

Raphael P.H. Meier MD1

Division of Visceral Surgery Faculty of Medicine, University of Geneva

Geneva university hospitals 1211 Geneva 14, Switzerland

E-mail address: [email protected]

Christian Toso MD, PhD1 Division of Visceral and Transplant Surgery Faculty of Medicine, University of Geneva

Geneva University Hospitals 1211 Geneva 14, Switzerland

E-mail address: [email protected]

Francesco Volonte MD1 Division of Visceral Surgery, Faculty of Medicine University of Geneva, Geneva University Hospitals

1211 Geneva 14, Switzerland E-mail address: [email protected]

Gilles Mentha MD1 Division of Transplant Surgery, Faculty of Medicine University of Geneva, Geneva University Hospitals

1211 Geneva 14, Switzerland E-mail address: [email protected]

doi:10.1016/j.ajem.2010.02.025

References

  1. Barriot P, Riou B. Hemorrhagic shock with paradoxical bradycardia. Intensive Care Med 1987;13(3):203-7.
  2. Petersen CR, et al. Splenic injury after colonoscopy. Endoscopy 2008;40(1):76-9.
  3. Duarte CG. Splenic rupture after colonoscopy. Am J Emerg Med 2008;26(1):117.e1-3.

1 Author involvement: Meier, drafting of the manuscript; Toso, Volonte, Mentha, critical revision of the manuscript for important intellectual content.