S1842 Splenic Laceration: A Life-Threatening Colonoscopy Complication

Abstract

INTRODUCTION: Splenic laceration is a rare but potentially fatal complication of an otherwise safe and effective procedure in colonoscopy. The most commonly associated complications of the procedure include hemorrhage (1.8-2.5%) and perforation (0.34-2.14%). Patient risk factors for splenic laceration include adhesions, female sex, and anticoagulation. Procedural risk factors include hooking of the splenic flexure, alpha maneuver, and application of pressure at the left hypochondrium. Here, we present the case of a 59-year-old male on dual anti-platelet therapy who underwent colonoscopy complicated by splenic laceration. CASE DESCRIPTION/METHODS: A 59-year-old male with recent history of colonoscopic adenomatous polypectomy underwent follow-up colonoscopy with subsequent development of post-operative hemodynamic instability. Medical history was significant for MI status-post cardiac catheterization with 2 stents to RCA on dual anti-platelet therapy, held for 7 days prior to the procedure, and a beta-blocker. On initial attempt at endoscopy, the patient was found to have suboptimal bowel prep and scheduled for follow-up colonoscopy the next day. Despite repeat suboptimal prep, the procedure was performed uneventfully and accomplished without resistance or looping. 10 hours post-discharge, the patient presented to the ED with 10/10 LUQ pain radiating to the left shoulder. At this time, the patient was pale and diaphoretic with BP 82/50 and HR 72/min. On exam, there was marked tenderness in the LUQ with voluntary guarding and without rebound. Laboratory evaluation revealed WBC 14.4 × 103/µL; Hb 8.9 g/L; platelets 420 × 103/µL. Troponins were normal, and EKG showed non-specific abnormalities. CT of the abdomen revealed a large peri-splenic hematoma 13.7 × 13.5 cm with moderate hemoperitoneum, but without distinctive splenic laceration. Despite a transient response to fluid resuscitation, the patient’s hemodynamic status continued to deteriorate, necessitating transfusion and subsequent splenectomy indicated for active bleeding from a splenic pedicle. DISCUSSION: Splenic laceration is a rare complication of colonoscopy (incidence 0.00005–0.17%) associated with significant mortality (5%), and as such requires a low threshold of suspicion for early diagnosis and management in the post-colonoscopy period. Anticoagulation, a requisite for management of cardiovascular comorbidities, is a notable risk factor and may predispose to splenic capsular rupture with minimal colonoscopic manipulation.Figure 1.: CT abdomen demonstrating large peri-splenic hematoma (13.7 × 13.5 cm) with moderate hemoperitoneum.