Difficult Colonoscopy Research Articles

Unable to exit during difficult colonoscopy examination

Unable to exit during difficult colonoscopy examination

Gastroscope Application in Difficult Colonoscopy: An Effective Alternative for Patients with Gynecologic Oncology

Gastroscope Application in Difficult Colonoscopy: An Effective Alternative for Patients with Gynecologic Oncology

An Unexpected Difficult Colonoscopy Caused by Right-Sided Sigmoid Colon.

An Unexpected Difficult Colonoscopy Caused by Right-Sided Sigmoid Colon.

S179 Enhancing Colonoscopy Outcomes: A Systematic Review of the Clinical Effectiveness of a Novel Rigidizing Overtube in Completing Difficult Colonoscopies and Achieving Complex Polyp Resection

S179 Enhancing Colonoscopy Outcomes: A Systematic Review of the Clinical Effectiveness of a Novel Rigidizing Overtube in Completing Difficult Colonoscopies and Achieving Complex Polyp Resection

Strategies to manage the difficult colonoscopy.

During endoscopy, an endoscopist is inevitably faced with the occasional "difficult colonoscopy," in which the endoscopist finds it challenging to advance the endoscope to the cecum. Beyond optimization of technique, with minimized looping, minimal insufflation, sufficient sedation, and abdominal splinting when needed, sometimes additional tools may be needed. In this review, we cover available techniques and technologies to help navigate the difficult colonoscopy, including the ultrathin colonoscope, rigidizing overtube, balloon-assisted colonoscopy and the abdominal compression device.

Review of oral and pharyngolaryngeal benign lesions detected during esophagogastroduodenoscopy.

Recent advancements in endoscopy equipment have facilitated endoscopists' detection of neoplasms in the oral cavity and pharyngolaryngeal regions. In particular, image-enhanced endoscopy using narrow band imaging or blue laser imaging play an integral role in the endoscopic diagnosis of oral and pharyngolaryngeal cancers. Despite these advancements, limited studies have focused on benign lesions that can be observed during esophagogastroduodenoscopy in the oral and pharyngolaryngeal regions. Therefore, this mini-review aimed to provide essential information on such benign lesions, along with representative endoscopic images of dental caries, cleft palate, palatal torus, bifid uvula, compression by cervical osteophytes, tonsil hyperplasia, black hairy tongue, oral candidiasis, oral and pharyngolaryngeal ulcers, pharyngeal melanosis, oral tattoos associated with dental alloys, retention cysts, papilloma, radiation-induced changes, skin flaps, vocal cord paresis, and vocal fold leukoplakia. Whilst it is imperative to seek consultation from otolaryngologists or dentists in instances where the diagnosis cannot be definitively ascertained by endoscopists, the merits of attaining foundational expertise pertaining to oral and pharyngolaryngeal lesions are unequivocal. This article will be a valuable resource for endoscopists seeking to enhance their understanding of oral and pharyngolaryngeal lesions.

Candy cane syndrome: A systematic review.

Candy cane syndrome (CCS) is a condition that occurs following gastrectomy or gastric bypass. CCS remains underrecognized, yet its prevalence is likely to rise due to the obesity epidemic and increased use of bariatric surgery. No previous literature review on this subject has been published. To collate the current knowledge on CCS. A literature search was conducted with PubMed and Google Scholar for studies from May 2007, until March 2023. The bibliographies of the retrieved articles were manually searched for additional relevant articles. Twenty-one articles were identified (135 patients). Abdominal pain, nausea/vomiting, and reflux were the most reported symptoms. Upper gastrointestinal (GI) series and endoscopy were performed for diagnosis. Surgical resection of the blind limb was performed in 13 studies with resolution of symptoms in 73%-100%. In surgical series, 9 complications were reported with no mortality. One study reported the surgical construction of a jejunal pouch with clinical success. Six studies described endoscopic approaches with 100% clinical success and no complications. In one case report, endoscopic dilation did not improve the patient's symptoms. CCS remains underrecognized due to lack of knowledge about this condition. The growth of the obesity epidemic worldwide and the increase in bariatric surgery are likely to increase its prevalence. CCS can be prevented if an elongated blind loop is avoided or if a jejunal pouch is constructed after total gastrectomy. Diagnosis should be based on symptoms, endoscopy, and upper GI series. Blind loop resection is curative but complex and associated with significant complications. Endoscopic management using different approaches to divert flow is effective and should be further explored.

A121 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH PANCREATICODUODENECTOMY USING DYNAMIC RIGIDIZING OVERTUBE

Abstract Background Dynamic rigidizing overtubes have recently been described as a useful tool in challenging endoscopic procedures. These devices have the ability to dynamically rigidize, which stabilizes endoscope position, reduce loop formation and assist in the traversal of acute angulation. Its use has been best described in difficult colonoscopies by preventing loop formation and subsequently facilitating cecal intubation. However, the use of rigidizing overtubes for endoscopic retrograde cholangiopancreatography is sparsely described in the literature. In particular, rigidizing overtubes may be beneficial in patients with surgically-altered anatomy, including post-pancreaticoduodenectomy (PD) patients, as traversal to the surgical anastomosis is often challenging because of loop formation and acute angulation. In this study, a retrospective analysis was conducted on post-PD patients undergoing ERCP with dynamic rigidizing overtube. Purpose The purpose of this study was to evaluate the technical and clinical success of post-PD patients undergoing ERCP with rigidizing overtube. Method A retrospective analysis was conducted on all post-PD patients who underwent ERCP with rigidizing overtube between 2006 and 2021. Demographic information including age, gender and primary malignancy was collected. Pertinent procedure-related information including indication and anastomosis identification was obtained. The primary outcomes evaluated included technical and clinical success rate. Technical success (TS) was defined as the ability to perform an intended therapeutic intervention (stent insertion, cannulation, etc). Clinical success (CS) was operationalized as improvement in patient symptoms or normalization of bilirubin. Result(s) A total of 5 patients underwent 11 ERCPs with rigidizing overtube for biliary indications. There was a total of 3 (60.0%) male and 2 (40.0%) female patients. The average age of the patients was 62.5 years of age. There were 3 (60.0%) patients with pancreas cancer, 1 (20.0%) with metastatic renal cell carcinoma, and 1 (20.0%) with duodenal adenoma with high grade dysplasia. The indications for ERCP included stent evaluation (n = 6; 54.5%), obstructive jaundice (n =3; 27.3%), cholangitis (n = 1; 9.1%), and stricture evaluation (n = 1; 9.1%). The surgical anastomosis was identified in all patients (n = 11; 100%). The overall technical and clinical success rates were both 90.9%. Conclusion(s) The use of rigidizing overtubes in ERCP may be beneficial in patients with surgically altered anatomy. In this small sample, technical and clinical success rates were excellent in post-PD patients. However, additional studies need to be conducted to validate these findings further. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

WEO Newsletter.

WEO Newsletter.

S644 ColoWrap Real-World Evidence: Colonoscopy Compression Device Mitigates Ergonomic Hazards for Endoscopists and Staff

Introduction: Looping during colonoscopy increases scope forces and torquing which are causes of ergonomic injury among endoscopists. In addition, manual abdominal pressure and patient repositioning, used to address looping in 52% and 34% of colonoscopies, respectively, are known causes of musculoskeletal injuries among endoscopy staff. ColoWrap (ColoWrap, LLC, Durham, NC) is an anti-looping abdominal compression device applied during colonoscopy to decrease looping and limit the need for manual pressure and patient repositioning. We aimed to determine extent to which ColoWrap reduces ergonomic hazards associated with colonoscopy by performing a chart review and obtaining physician and staff feedback following use of the device. Methods: This retrospective, multi-center, observational chart review included patients that underwent colonoscopy with the ColoWrap device between September 25, 2016, and June 15, 2022. Demographics and procedural information were abstracted from patient records. Physician and staff experiences were captured using a survey instrument. Results: 849 procedures were included in the review. The population was majority male (53%), over 60 (mean age: 60.8 ± 11.6), and obese (mean BMI: 33.6 ± 7.2). 49 patients (5.7%) had an abdominal hernia, 139 (16.3%) had at least one prior abdominal surgery, and 52 (6.1%) had a history of difficult or incomplete colonoscopy. Cecal intubation was achieved in 841 cases (99.1%). Mean cecal intubation time was 6.8 ± 6.2 (min). Manual pressure was used in 109 cases (12.8%); significant manual pressure ( > 3 min) was needed in only 21 procedures (2.5%). Patient repositioning was used in 48 cases (5.6%). No significant adverse events were reported. 84% of physicians indicated that ColoWrap use mitigated looping, shortened cecal intubation time, and reduced physical strain associated with advancing the scope. 90% of endoscopy staff reported reduced manual pressure and patient repositioning, and alleviation of musculoskeletal pain (Figure). Conclusion: ColoWrap is safe and significantly reduces manual pressure and patient repositioning during colonoscopy relative to published rates. Physicians using ColoWrap experience less looping and physical strain and endoscopy staff suffer less musculoskeletal pain. The device is a viable tool among solutions to improve the safety and efficiency of colonoscopy. Further studies to identify circumstances in which ColoWrap use offers the greatest benefit to patients, physicians, and staff are warranted.Figure 1.: Endoscopist and Endoscopy Staff Experience with ColoWrap Device

S2384 The First Case of Water Immersion Endoscopy in the Definitive Diagnosis of Atrio: Esophageal Fistula

Introduction: Atrial fibrillation (AF) is the most common heart rhythm disorder with estimated global prevalence of 33.5 million. Catheter ablation is the treatment modality of choice for refractory AF. Atrio-esophageal fistula (AEF) is a serious complication of catheter ablation. Diagnosis is critical to the management of AEF, and includes computed tomography of the chest, esophagram and esophagogastroduodenoscopy (EGD). Prompt diagnosis of AEF is essential for survival. Case Description/Methods: A 56-year-old male with AF presented with fever, fatigue and bilateral leg weakness. Twenty days prior to presentation he underwent pulmonary vein isolation radiofrequency ablation and discharged the following day. Upon re-presentation his vitals were notable for fever and tachycardia. Labs revealed a normal white count and hemoglobin, and elevated lactate and troponin. One hour after arrival he developed complex focal seizure and AF with rapid ventricular rate followed by respiratory decompensation requiring intubation. His blood cultures revealed Streptococcus mitis and Gemella haemolysans. His MRI disclosed numerous bilateral emboli concerning for endocarditis, however TEE did not reveal any valvular vegetation, thus proposing AEF as a possible complication accounting for the emboli. CT chest angiogram revealed subtle irregularity along the posterior wall of the left atrium (figure A), but did not provide conclusive evidence to warrant high-risk cardiothoracic surgery. Water immersion EGD was performed to diagnose and localize the fistula, revealing esophageal defect in the proximal esophagus with movement of non-bloody debris through the tract (figure B). One hemostatic clip was placed near the tract to assist with localization for surgical closure. The following day the patient underwent right thoracotomy with placement of intercostal muscle flap to fistula (Figure C). Discussion: AEF is a rare complication of radiofrequency ablation therapy for AF. High mortality rate is primarily attributed to major cerebrovascular morbidity from septic thrombi. Currently there is no effective modality to visualize AEF safely and reliably. Water immersion colonoscopy allows for completion of difficult colonoscopies, decreased insertion pain, and increased adenoma-detection rates. This technique was applied to identify the AEF. Water immersion EGD is an important modality that can confidently be considered within the diagnostic armamentarium of gastroenterologists to ensure safe and rapid diagnosis and treatment of AEF.Figure 1.: 1: (A) Illustrates a subtle contour abnormality involving the posterior wall of the left atrium (arrow) concerning for AEF (B) Water immersion endoscopy illustrating 3mm defect (arrow) in the wall of the esophagus (C) Underwent right thoracotomy to access AEF. This image highlights 3mm fistula site (arrow) that is approximated to be at the midpoint of the atrium.

Feasibility of salvage colonoscopy by water exchange for failed air-insufflated patients: a prospective, randomized, controlled trial

Background A complete colonoscopy is crucial for screening colorectal diseases and colorectal cancer. However, a failure rate of up to 43% still exists. Several studies have indicated that the water exchange method can enhance the cecal intubation rate while reducing discomfort of the patient. Water exchange colonoscopy (WEC) might be a salvage treatment for the patients who failed from air insufflation colonoscopy (AIC). We aimed to assess the feasibility of WEC as a salvage measure following the failure of conventional AIC Methods Patients willing to undergo unsedated colonoscopy at a tertiary-care referral center in China were randomly assigned 1:1 to WEC or AIC group for salvage after the initial AIC attempt failed. Patients were blinded to group assignment. The primary outcome was cecal intubation rate, the secondary outcomes included time to the cecum, maximum pain scores, and technical difficulty level. Results Recruited 104 patients were randomized to the WEC (n = 52) or AIC (n = 52) group. WEC significantly increased the cecal intubation rate (92.3% vs 73.1%; p = .02). The maximum pain scores and technical difficulty level in the WEC group were significantly lower than the AIC group during salvage procedure (p < .001). Conclusions This randomized, controlled trial confirms that the WEC significantly enhanced cecal intubation rate in difficult colonoscopy in unsedated patients after the failure of standard AIC. The increased cecal intubation rate, lower pain scores and technical difficulty level suggest WEC is a good alternative for incomplete unsedated colonoscopy. Clinical trial registration number: ChiCTR2100051483.

Achieving cecal intubation in the difficult colon (with videos)

How can one safely and effectively reach the cecum in a long, redundant, and loopy colon? This is a question that several of us ask ourselves during colonoscopy. In this edition of Top Tips from master endoscopists, Dr Doug Rex, president of the American Society for Gastrointestinal Endoscopy, provides us with clear and precise insights for this important topic. Starting from endoscope selection and patient positioning and continuing to loop reduction, Doug, as always, does a masterful job of walking us through the steps on how to approach a patient during a difficult colonoscopy.

A Novel Dynamic Rigidizing Overtube Significantly Eases Difficult Colonoscopy

Colonoscopy is a common procedure for colorectal cancer screening and evaluation of large intestinal pathology such as inflammatory bowel disease and lower gastrointestinal bleeding 1 Kasper DL Fauci AS Hauser SL et al. Harrison's principles of internal medicine 19/E (Vol.1 & Vol.2). 19th ed. McGraw-Hill Professional, 2015 Google Scholar . Colonoscopy allows both viewing of the large intestine up to the cecum and performance of procedures such as polypectomy and control of GI bleeding. 2 Haycock A Cohen J Saunders BP et al. Cotton and Williams’ practical gastrointestinal endoscopy: the fundamentals. John Wiley & Sons, Ltd, 2014 Google Scholar A successful screening colonoscopy involves viewing the entire colon including the cecum and being able to safely perform therapeutic procedures such as polypectomy and control of bleeding. 3 Rees CJ Bevan R Zimmermann-Fraedrich K et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut. 2016; 65: 2045-2060 Google Scholar There are various barriers to successfully completing a colonoscopy including colon looping, poor bowel prep, and patient intolerance of the procedure. 4 Wong JYY Ho KY. Robotics for advanced therapeutic colonoscopy. Clin Endosc. 2018; 51: 552-557 Google Scholar , 5 Serper M Gawron AJ Smith SG et al. Patient factors that affect quality of colonoscopy preparation. Clin Gastroenterol Hepatol. 2014; 12: 451-457 Google Scholar For the practicing endoscopist, looping of the colon can be a significant barrier to successful completion of colonoscopy. This often leads to suboptimal outcomes including prolonged anesthesia, limited examination and therapy, and overall diminished patient care.

ID: 3522396 A NEW, SIMPLE ENTEROSCOPY TECHNIQUE USING A NOVEL DYNAMIC RIGIDIZING OVERTUBE IN A SINGLE ACADEMIC MEDICAL CENTER

Single or double balloon enteroscopy is able to visualize the small bowel well but is not readily available due to the cost and procedural expertise required. A novel dynamic rigidizing overtube is now available to assist with difficult colonoscopy. In its flexible state, the overtube material is soft and pliable, but in its rigid state becomes 15 times stiffer when a vacuum is applied. This aids in stability and minimizing loop formation. The aim of this study was to assess feasibility and safety of this novel device for use in performing antegrade and retrograde enteroscopy.

Cecal intubation time in screening colonoscopy.

The time required to intubate the cecum varies. The aim of this study was to determine whether demographic and anthropometric factors, such as body mass index (BMI), percent body fat, muscle mass, and fat mass, affect the cecal intubation time (CIT) during complete colonoscopy.A retrospective chart review of 1229 patients (aged 40–80 years) was performed. These patients underwent average-risk screening colonoscopies performed by expert gastroenterologists at Health Check-up Center, Seoul National University Bundang Hospital, during a health check-up. We collected data on age, sex, BMI, percent body fat, muscle mass, fat mass, history of prior abdominal or pelvic surgery, CIT, and bowel preparation quality (Boston Bowel Preparation Scale [BBPS] score).Of the 1229 patients, 62% were men. The mean age was 55 years, and the mean BMI was 24 kg/m2. The median CIT was 5 min. The patients were categorized into two groups according to CIT: easy colonoscopy (CIT ≤ 10 min) and difficult colonoscopy (CIT > 10 min). In univariate analysis, CIT was prolonged by the following factors: older age, poor bowel preparation, lower BMI, lower percent body fat, and less fat mass. Multivariate analysis showed that anthropometric indices including BMI, percent body fat, muscle mass, and fat mass were not significant factors for CIT. Older age (≥ 70 years) (odds ratio [OR]: 2.272, 95% confidence interval [CI]: 1.056–4.890, P = .036) and poor bowel preparation (BBPS score ≤ 5) (OR: 3.817, 95% CI: 1.866–7.808, P = .000) were found to be correlated with difficult colonoscopy.Our study suggests that anthropometric indices including BMI, percent body fat, muscle mass, and fat mass are not associated with significantly different CIT. Furthermore, sex and prior abdominal or pelvic surgery are not useful factors for a prolonged CIT. Older age (≥ 70 years) and poor bowel preparation (BBPS score ≤ 5) are significant variables predicting the CIT of expert gastroenterologists.

Magnetic endoscopic imaging as a rational investment for specific colonoscopies: a systematic review and meta-analysis

ABSTRACT Background Magnetic endoscopic imaging (MEI) was regarded as an adjuvant device to improve procedural efficacy and patients’ comfort during colonoscopy. Methods Several electronic databases were searched to identify eligible studies. Based on the heterogeneity of included studies, random-effects or fixed-effects models were used to calculate pooled risk ratios (RR), risk difference (RD) or mean difference (MD) along with 95% confidence intervals (CIs). Results Twenty-one randomized controlled trials (RCTs) were selected for meta-analysis, with a total of 7,060 patients. Although there is a slightly lower risk of cecal intubation failure with the adjuvant of MEI (RD 3%; P < 0.00001) compared to the control group, the updated studies show no significant benefits. Similarly, the cecal intubation time, pain scores, and loop formation with the adjuvant of MEI did not show any advantages. However, considerable significant benefits were found in the subgroup of technically difficult colonoscopy and inexperienced colonoscopists. Moreover, MEI was associated with lower loop intubation time, lower abdominal compression times, and better lesion localization. Conclusion The clinical benefits of MEI could be exaggerated. However, MEI has considerable advantages in technically difficult colonoscopies, the assistance for inexperienced colonoscopists, loop resolving, and lesion localization.

Impact of cap-assisted colonoscopy during transendoscopic enteral tubing: A randomized controlled trial.

Colonic transendoscopic enteral tubing (TET) requires double cecal intubation, raising a common concern of how to save cecal intubation time and make the tube stable. We hypothesized that cap-assisted colonoscopy (CC) might reduce the second cecal intubation time and bring potential benefits during the TET procedure. To investigate if CC can decrease the second cecal intubation time compared with regular colonoscopy (RC). This prospective multicenter, randomized controlled trial was performed at four centers. Subjects ≥ 7 years needing colonic TET were recruited from August 2018 to January 2020. All subjects were randomly assigned to two groups. The primary outcome was the second cecal intubation time. Secondary outcomes included success rate, insertion pain score, single clip fixation time, purpose and retention time of TET tube, length of TET tube inserted into the colon, and all procedure-related (serious) adverse events. A total of 331 subjects were randomized to the RC (n = 165) or CC (n = 166) group. The median time of the second cecal intubation was significantly shorter for CC than RC (2.2 min vs 2.8 min, P < 0.001). In patients with constipation, the median time of second cecal intubation in the CC group (n = 50) was shorter than that in the RC group (n = 43) (2.6 min vs 3.8 min, P = 0.004). However, no difference was observed in the CC (n = 42) and RC (n = 46) groups of ulcerative colitis patients (2.0 min vs 2.5 min, P = 0.152). The insertion pain score during the procedure in CC (n = 14) was lower than that in RC (n = 19) in unsedated colonoscopy (3.8 ± 1.7 vs 5.4 ± 1.9; P = 0.015). Multivariate analysis revealed that only CC (odds ratio [OR]: 2.250, 95% confidence interval [CI]: 1.161-4.360; P = 0.016) was an independent factor affecting the second cecal intubation time in difficult colonoscopy. CC did not affect the colonic TET tube's retention time and length of the tube inserted into the colon. Moreover, multivariate analysis found that only endoscopic clip number (OR: 2.201, 95%CI: 1.541-3.143; P < 0.001) was an independent factor affecting the retention time. Multiple regression analysis showed that height (OR: 1.144, 95%CI: 1.027-1.275; P = 0.014) was the only independent factor influencing the length of TET tube inserted into the colon in adults. CC for colonic TET procedure is a safe and less painful technique, which can reduce cecal intubation time.

S0169 A Novel Dynamic Rigidizing Overtube Significantly Eases Difficult Colonoscopy

INTRODUCTION: Looping colons challenge endoscopists, prolong anesthesia, and limit examination and therapy. Failure due to a looping colon results in suboptimal patient care and causes mental and physical fatigue on the endoscopist. A novel rigidizing overtube is now available to reduce looping and facilitate colonoscopy completion. In its flexible state, the overtube material is soft and pliable; in its rigid state it becomes fifteen times stiffer, aiding in stability and minimizing loop formation. In this study, we examine if a rigidizing overtube can salvage colonoscopies previously terminated due to challenging looping of the colon and reduce the overall perceived workload. METHODS: This is a prospective single center experience over a 6 month period using a novel dynamic rigidizing overtube for assistance during difficult colonoscopy. Difficult colonoscopy subjects were categorized as based on: looping that prevented reaching the cecum despite position change and abdominal counter pressure (LOOP group) or poor stabilization to perform therapeutic polypectomy (UNSTABLE group). Parameters assessed included successful/failed salvage of the procedure, and the in-procedure NASA Task Load Index (TLX) before and after use of the rigidizing overtube. The TLX raw and weighted scores were compared for each type of demand (mental, physical, effort, temporal, performance and frustration). RESULTS: Over the study period, there were 14 difficult colonoscopy procedures 8 in the LOOP group and 6 in the UNSTABLE group. In the LOOP group, all 8 cases were salvaged, and cecum was reached after device was used. The TLX weighted score decreased from 81.1 to 26.0 after use (P < 0.01). In the UNSTABLE group, complete polypectomy was successful in all cases. The TLX weighted score decreased from 79.7 to 40.4 after use (P < 0.01). In all procedures, the TLX raw scores for each type of demand was reduced (Figure 1; all P < 0.05). CONCLUSION: In this early series, a novel dynamic rigidizing overtube was able to successfully assist in salvaging difficult colonoscopy due to looping and assist in complex polypectomy by improving stabilization. In addition, the endoscopist’s in-procedure perceived workload significantly decreased after use of the device. This novel rigidizing overtube has potential to help salvage difficult endoscopic cases as well as decrease the workload of the endoscopist during difficult procedures.Figure 1.: Image of the rigidizing overtube. The overtube is placed at the hub of the colonoscope, allowing free tip movement. When the vaccum is applied, the normally flexible overtube becomes fifteen times as rigid, allowing 1 to 1 movement when force is applied to the shaft of the colonoscope.Figure 2.: Means of raw NASA-TLX demand scores before and after use of the rigidizing overtube in difficult colonoscopies. All score changes were statistically significant.

S3440 A Rare but Serious Complication of Colonoscopy

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).