1877 An Unfortunate Turn of Events: A Rare Case of Splenic Hematoma Following Colonoscopy for Post-Polypectomy Bleeding

Abstract

INTRODUCTION: Post-polypectomy bleeding has been reported to occur in 0.3 to 6.1% of colonoscopic polypectomies. Splenic injury after colonoscopy is a rare complication with a described incidence of less than 0.017%. CASE DESCRIPTION/METHODS: A 66-year-old male with a past medical history of hypertension was admitted with post-colonoscopic polypectomy bleed. He underwent a colonoscopy in July 2018 for a history of adenomatous polyps. The colonoscopy revealed multiple non-bleeding polyps (about 15) throughout the large bowel and 8 polyps were removed with endoscopic mucosal resection (EMR). A follow up colonoscopy was performed for resection of the remaining polyps in October 2018. He presented to the hospital one-week post second colonoscopy with acute onset of hematochezia. On presentation, he was afebrile, with HR 64 and BP 108/62. Labs were notable for hemoglobin of 7.1 g/dl (from a baseline of 11 to 12 g/dl) concerning for post-polypectomy bleeding. Colonoscopy repeated after admission showed no active bleeding; a clean based ulcer was noted in the transverse colon at the site of EMR which was the likely source of bleeding. Hospital course was complicated by severe left upper quadrant pain and shock with BP dropping to 70s/40s requiring ICU admission one day after the colonoscopy. He was found to be coagulopathic with an INR of 4.9 requiring vitamin K and FFP. Hemoglobin dropped to 5.3 g/dl and he received a total of 10 units of pRBC transfusions. CTA abdomen/pelvis showed a splenic hematoma measuring 12.3 x 10 x 17 cm. Splenectomy was deferred per surgery recommendations and coil embolization of the proximal splenic artery was successfully performed. He improved clinically after splenic artery embolization and was discharged home with follow-up. DISCUSSION: Splenic injury is a potentially catastrophic complication of colonoscopy with a reported mortality of about 5%. Several mechanisms of splenic injury associated with colonoscopy have been described which include difficult procedure, traction on the splenocolic ligament, external abdominal pressure during colonoscopy, perforation of the splenic flexure and direct trauma to the spleen, and traction of adhesions between the spleen and colon. Patient-related risk factors such as abdominal surgeries leading to adhesions, splenomegaly and pancreatitis increase the likelihood of splenic injury during the procedure. With increasing number of cases, further studies are required to re-assess the incidence and risk factors for splenic injury after colonoscopy.