Hidden Risks of Colonoscopy Bowel Preparation in the Elderly: Case Report of Rib Fracture

Abstract

Introduction: An 82-year-old man with a history of a deep vein thrombosis, on anticoagulation with rivaroxaban, presented to an outside hospital with multiple episodes of dark red blood per rectum. His hemoglobin had declined from 11.3 to 9.1. EGD and colonoscopy revealed blood in the colon and ileum but no specific source of bleeding. He was transferred to our institution for further evaluation. Past medical history was notable for atrial fibrillation, aortic aneurysm repair, heart failure, right subclavian DVT, and hypothyroidism. In addition to rivaroxaban, he was also taking aspirin 81 mg once daily. Upon arrival at our institution, he was hemodynamically stable with no ongoing bleeding. As the initial colonoscopy revealed no specific source of blood loss, the GI consult team recommended repeat colonoscopy and, if negative for a bleeding source, video capsule endoscopy. The patient began bowel preparation with PEG-3350 in the late afternoon. At approximately 8 PM, he fell after standing from his bedside commode, striking a chair with the left side of his body. There was no loss of consciousness, and the fall was thought to be mechanical in origin. Radiographs demonstrated multiple left-sided rib fractures. He had minimal pain and did not require analgesia or experience respiratory discomfort. He completed the bowel preparation without further incident. His colonoscopy revealed a bleeding AVM which was treated with argon plasma coagulation with cessation of bleeding. His hemoglobin remained stable and he was discharged the following day. This case demonstrates an underappreciated risk of colonoscopy: mechanical falls associated with bowel preparation. While other complications of colonoscopy are well described, the incidence and significance of falls during bowel preparation is not well known. Prior published case reports of trauma during colonoscopy preparation include hypotensive syncope with maxillofacial trauma and a mechanical fall with intracranial bleeding from head trauma. To our knowledge, this is the first reported case of a rib fracture during colonoscopy preparation. The challenges of colonoscopy preparation in elderly hospitalized patients, including frequent trips to and from a toilet or commode in an unfamiliar environment, may put patients at increased risk of falls. Future studies may be able to define the epidemiology of these uncommon but serious events and ultimately lead to interventions to mitigate fall risks.