1908 Iatrogenic Severe Rupture of the Spleen Following Colonoscopy

Abstract

INTRODUCTION: Splenic injury is a rare complication of colonoscopy, with about 100 reported cases worldwide. Identification of splenic injury following colonoscopy is challenging given its non-specific presentation and low incidence. This case report highlights the importance of a high index of suspicion in patients with vague abdominal symptoms post colonoscopy and the need to increase awareness for splenic injury as a possible complication of colonoscopy. CASE DESCRIPTION/METHODS: A 72-year-old female presented to the ER with left upper quadrant (LUQ) abdominal pain and weakness 8 hours after a diagnostic colonoscopy. Past medical history included DVT and multiple episodes of PE, for which she was on Coumadin. Coumadin was held prior to colonoscopy. PT and the INR on the day of the procedure were 19.0s and 2.0. Normal findings with no technical difficulties, therapeutic interventions, or biopsies taken during colonoscopy. At discharge, she remained asymptomatic, and Coumadin was resumed. On return, exam revealed normal vital signs and distended abdomen with LUQ tenderness. Labs showed: hgb = 8.1, PT = 15.3s, INR = 1.6, and aPTT = 22.3s. CT revealed peri-splenic fluid collection suspicious for hemorrhage or subcapsular hematoma with free fluid extending into the pelvis. Coumadin was discontinued, and she was managed non-operatively with serial abdominal exams and hemoglobin measurement. Hemoglobin remained stable without requiring blood transfusions. Coumadin was resumed on day 4 and hemoglobin was monitored for another 48 hours, remaining stable at 9.0 g/dl. DISCUSSION: Splenic injury is a rare complication of colonoscopy with a reported incidence of 1:6,000 to 1:100,000 colonoscopies performed. Associated symptoms are non-specific with significant variability in timing of onset, posing a diagnostic dilemma for clinicians. Most patients with splenic injury present within 24 hours post procedure. However, some may present after 10–14 days. LUQ abdominal pain is the most common symptom, although in some cases, patients may be asymptomatic. Hypotension, anemia, and elevated white blood cell count may be present as well. Anti-coagulants and anti-platelets have been shown to not increase the risk of splenic injury during colonoscopy. The most accurate test for diagnosing splenic injury is abdominal CT, with a 98 % specificity and sensitivity. Splenic hematoma represents a rare complication of colonoscopy and should be included in the differential for a patient complaining of abdominal pain following the procedure.