S3440 A Rare but Serious Complication of Colonoscopy

Abstract

INTRODUCTION: Reading View. Press Alt Shift A for accessibility help. Colonoscopy is the most widely used procedure for many colonic diseases. Hemorrhage and perforation are the most common complications. Splenic injury after colonoscopy is a very rare yet serious complication. Here we present a case followed by the review of literature. CASE DESCRIPTION/METHODS: Reading View. Press Alt Shift A for accessibility help. A 71-year-old woman presented with left lower abdominal pain after undergoing routine colonoscopy three days prior. She had history of right hemicolectomy for colonic carcinoma. Her exam showed tenderness in the left lower quadrant and epigastric area. Labs were significant for hemoglobin 10.7 g/dL (baseline 11 g/dL). CT abdomen revealed a 6.2 × 2.3 × 5.1 cm hematoma surrounding the lower pole of the spleen (Figure 1). She was managed conservatively with fluid resuscitation. CT angiography showed no active bleeding. Her hemoglobin remained stable and she did not require any surgical intervention. DISCUSSION: Reading View. Press Alt Shift A for accessibility help. Splenic injury is an under-reported complication of colonoscopy, with only 103 cases reported until 2012. The first ever case of splenic injury was reported in 1974 by Wherry and Zehner with the incidence of around 0.00005-0.017% and a mortality rate of 5%. Risk factors for splenic injury post-colonoscopy are previous surgical adhesions, as in our patient, IBD, difficult colonoscopy, rushing during the procedure and insufficient visualization due to poor bowel preparation. Splenic capsular avulsions and lacerations are caused either by direct injury during manipulation through the splenic flexure or during a difficult colonoscopy owing to transcolic pressure or looping of the instrument. Technical maneuvers during colonoscopy such as the alpha maneuver, straightening of the sigmoid loop, external pressure on the left hypochondrium also increase the risk. The most common symptom is left upper quadrant pain, with referred pain to the left shoulder known as the Kehr sign. Symptoms usually present within 24 hours. CT abdomen is the best imaging modality. Splenic injury post colonoscopy is treated either conservatively or through surgical intervention depending upon the hemodynamic status of patient and size of hematoma. Conservative management includes fluid resuscitation or blood product replacement. Surgical intervention is recommended for hemodynamic instability or Grades IV-V splenic lacerations.Figure 1.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).Figure 2.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).