Delayed Diagnosis of Splenic Hematoma after Routine Colonoscopy

Abstract

Purpose: Sixty-seven cases of splenic hematoma after colonoscopy have been reported in the literature. This complication is rare, however it is associated with significantly increased morbidity and mortality. We report a case of a large splenic hematoma following colonoscopy, highlighting a delay in the diagnosis of this complication. Methods: A 46-yr-old woman with a family history of colon cancer underwent an elective outpatient screening colonoscopy. She did not use anti-platelet or anti-coagulant agents prior to the procedure. The procedure was uneventful with intubation of the cecum. The patient tolerated the procedure well. Numerous colonic diverticula and a single 5 mm polyp in the rectosigmoid region were noted. Polypectomy was performed using cold biopsy forceps. Results: She presented to her family practitioner 8 days following the procedure with a sharp left upper quadrant pain radiating to the sternum and left shoulder tip. The pain was worse with deep inspiration and unchanged with movement of the left shoulder joint. The physical examination was unremarkable except for mild diffuse abdominal tenderness. A 12 lead electrocardiogram was normal. She was treated with omeprazole 20 mg po daily for presumed gastroesophageal reflux disease. Musculoskeletal pain due to faulty sleep position was thought to be the cause of her shoulder pain and she was therefore instructed not to lie on the affected shoulder. Six weeks later, she presented to the Emergency Department with similar complaints, which had been continuous with no improvement after the empirical therapy. A chest x-ray showed blunting of the left costophrenic angle. The blood tests revealed normal complete blood count, metabolic profile, liver enzymes, serum amylase and serum lipase levels. She was treated with levofloxacin for presumed pneumonia. A subsequent contrast enhanced chest and abdominal CT found a large (9 × 6.3 × 11 cm) subcapsular splenic fluid collection, which was confirmed by an ultrasound exam. A total of 360 ml of old blood and fluid were drained percutaneously with ultrasound guidance. The patient made an uneventful recovery with resolution of her symptoms. A 4-week follow-up ultrasound showed complete resolution of the splenic hematoma. Conclusion: To our knowledge, the delay to diagnosis from the colonoscopy is the longest reported in a patient with continuous symptoms. This case highlights the need for a high index of suspicion for splenic injury after colonoscopy in order to avoid a delayed or missed diagnosis. With the higher number of colonoscopies performed each year in the United States, it is likely that this complication is significantly under recognized and reported.