Pateʼ or Perforation: A Transcolonic Liver Biopsy?

Abstract

A 68 year old woman underwent screening colonoscopy. The cecum was reached, but residual stool was present throughout the colon. A total of 7 sessile polyps ranging from 5-8 mm were removed successfully using hot snare polypectomy between the ascending colon and splenic flexure. One additional multilobulated polyp 2 cm in diameter was removed from the proximal transverse colon with a hot snare. Post-procedure recovery was routine, and the patient was asymptomatic at discharge. Three days later, the attending pathologist called after initial specimen review. She announced hepatic tissue was present on the third specimen, a proximal ascending colon polyp, and suggested the patient had transcolonic sampling of her hepatic parenchyma. The patient was called and reported mild upper abdominal discomfort. She denied any fever, chills or abdominal distention, and was tolerating a normal diet while passing flatus and stool. On further questioning, she noted her pre-procedure diet included liver ingested a few days before the colonoscopy. Given concern for an unrecognized perforation, she was advised to go to the emergency department, where a CT scan showed no evidence of perforation or bleeding and she was discharged home. Complete review of all pathology specimens demonstrated no evidence of hepatic parenchyma on any other slides. A literature search revealed no cases where hepatic injury occurred during colonoscopy as a result of transmural passage of polypectomy tools. Images from the colonoscopy report were reviewed and demonstrated no evidence of a tissue defect at any polypectomy site. This information, combined with the lack of thermal injury seen on the liver specimen, led to decreased concern for transcolonic hepatic biopsy. Another possibility, contamination with a liver biopsy prepared in the same laboratory, was deemed less likely given review of records showing no liver biopsies on the processing date. To assess the final possibility, ingested animal liver retained in the colon due to incomplete preparation, the attending pathologist obtained the patient's recipe and prepared the same dish. Raw and cooked samples of this liver were sectioned for review. Neither sample had an appearance similar to the findings on the colonic specimen. While the true origin of the colonic liver specimen is unknown, this case highlights the importance of a thorough investigation when unexpected pathology findings occur during routine endoscopy.Figure 1Figure 2