Jejunal Perforation Following Routine Colonoscopy

Abstract

Introduction: Bowel perforation following colonoscopy is a dreaded but rare complication. We report a case of jejunal perforation in a male patient following a screening colonoscopy. Case Report: A 77-year-old male with a past history of congestive heart failure cholecystectomy underwent a routine colonoscopy which revealed two 5 mm polyps in the rectum which were subsequently biopsied.The remainder of the colon was normal except for mild diverticulosis on the left side.Patient tolerated the procedure well without complications and was discharged. Within 24 hours he presented to the emergency room with diffuse abdominal pain, nausea and vomiting.Vital signs showed a blood pressure of 90/50mmHG and heart rate of 84 beats/min.Physical exam of the abdomen was consistent with diffuse tenderness, guarding and rigidity. Laboratory panel revealed a WBC count of 20,100/mm3 and creatinine of 2.7 mg/dL. Chest X-ray revealed no free air under the diaphragm, however non contrast CT of the abdomen revealed pneumoperitoneum and scattered foci of extra luminal gas consistent with perforation of the small bowel .Urgent exploratory laparotomy was performed which revealed small bowel perforation in the jejunum, extensive small bowel diverticulosis and a large abscess in the left paracolic gutter. 65 cm of small bowel was resected and end to end anastomosis was performed. His post-operative course was uneventful and was discharged.Histopathology was consistent with diffuse small bowel diverticulosis and acute serositis. Discussion: Colonic perforation is an uncommon but well documented complication of colonoscopy. In contrast perforation of the small bowel following a routine colonoscopy is rare. Perforation of the Ileum have been described in a few case reports1, however jejunal perforation is exceedingly rare. The mechanisms postulated includes excessive air insufflation and/or thermal injury during biopsy causing transmission of current across the cecal wall to the small bowel. The presence of jejunal diverticuli has been identified as a risk factor, as with this patient. Small bowel perforation often warrants surgical consultation and intervention. The physician must have a high index of suspicion to diagnose this dreaded complication since timely intervention can reduce mortality.Figure: Axial non contrast CT of the abdomen( soft tissue window) demonstrates multiple small bowel diverticula (yellow arrow).Figure: Non contrast CT demonstrates inflammation around the small bowel and omental fat stranding consistent with perforation (asterisk).Figure: Non-contrast axial CT of the abdomen( lung window) demarcates a small foci of free air (yellow arrow).