1452 Unusual Complication Following Screening Colonoscopy

Abstract

INTRODUCTION: Colonoscopy in general can be a challenging procedure as the colon is often quite mobile and tortuous. While abdominal pain is relatively common during and after the procedure, evaluation is always required to rule out serious causes such as colonic perforation and organ injury. CASE DESCRIPTION/METHODS: A 62-year-old female with a history of a left nephrectomy (23 years ago) underwent a screening colonoscopy (performed with good bowel preparation, under conscious sedation, and the whole colon was described as significantly redundant, tortuous and endoscopically normal) at the referring facility. She developed worsening left sided abdominal pain, nausea and vomiting three days after the procedure (managed at several occasions with bowel rest and antibiotics for presumed enteritis/diverticulitis). CT scan, 3 months following colonoscopy showed a complex irregular collection involving pancreatic tail and splenic flexure with adjacent partially rim-enhancing fluid collection abutting the greater curvature of the stomach. A CT guided percutaneous aspiration of fluid collection showed a markedly elevated lipase and amylase. This was concerning for pancreatic duct (PD) leak. She underwent an ERCP and placement of 3 Fr by 13 cm single pigtailed Advantix stent and 5 Fr by 3 cm Geenen stent for a confirmed PD leak. Although no definite fistulous communication to colon was seen on the fluoroscopic images, an immediate post ERCP non-contrast CT scan revealed contrast in the left colon concerning for a colo-pancreatic fistula. Her clinical symptoms resolved immediately following procedure. A follow up ERCP after 4 weeks confirmed no further PD leak. DISCUSSION: This patient's presentation is most consistent with chronic PD leak. The likely explanatory mechanisms include traction on fibrous surgical adhesions between the splenic flexure and distal pancreas, direct blunt trauma by passage of the colonoscope through the splenic flexure, and external abdominal pressure around the left colon. This case illustrates that it is possible for a patient with pre-existing risk factors to develop a significant pancreatic injury following colonoscopy. Careful review of patient's surgical history at time of informed consent is essential to identify those at risk and to take preventive measures including avoiding and reducing endoscope looping, avoiding excessive force and minimizing air insufflation.