Coagulation syndrome: Delayed perforation after colorectal endoscopic treatments

Abstract

Various procedure-related adverse events related to colonoscopic treatment have been reported. Previous studies on the complications of colonoscopic treatment have focused primarily on perforation or bleeding. Coagulation syndrome (CS), which is synonymous with transmural burn syndrome following endoscopic treatment, is another typical adverse event. CS is the result of electrocoagulation injury to the bowel wall that induces a transmural burn and localized peritonitis resulting in serosal inflammation. CS occurs after polypectomy, endoscopic mucosal resection (EMR), and even endoscopic submucosal dissection (ESD). The occurrence of CS after polypectomy or EMR varies according previous reports; most report an occurrence rate around 1%. However, artificial ulcers after ESD are largely theoretical, and CS following ESD was reported in about 9% of cases, which is higher than that for CS after polypectomy or EMR. Most cases of post-polypectomy syndrome (PPS) have an excellent prognosis, and they are managed conservatively with medical therapy. PPS rarely develops into delayed perforation. Delayed perforation is a severe adverse event that often requires emergency surgery. Since few studies have reported on CS and delayed perforation associated with CS, we focused on CS after colonoscopic treatments in this review. Clinicians should consider delayed perforation in CS patients.

ASGE review of adverse events in colonoscopy

“…2,33,52,53 The incidence is higher (7%-8%) in patients undergoing ESD. 54 PPES usually is managed with intravenous hydration, broad-spectrum parenteral antibiotics, bowel rest, and nothing by mouth until symptoms subside. 2,53 In a large multicenter study, hypertension, large lesion size (>2 cm), and nonpolypoid morphology were found to be independent predictors of PPES.…”

Colonoscopic Perforations

“…This full-thickness burn can lead to serosal inflammation and localized peritonitis. 21 Hirasawa et al defined postpolypectomy syndrome (PPS) as a subset of coagulation syndrome resulting after polypectomy or EMR. 21 Patients with PPS usually present with abdominal pain, fever, leukocytosis, elevated C reactive protein (CRP), or signs of localized peritonitis after use of electrocoagulation during colonoscopy.…”

“…Imaging studies do not show any signs of perforation. 21 The incidence of PPS is estimated to be 0.5 to 1.2%. Large lesion size and sessile lesions are risk factors for PPS.…”

“…22 Recognition of PPS and coagulation syndrome is important as it resolves with nonoperative treatment in most patients. 21,22 After ruling out perforation, patients are usually admitted for bowel rest and intravenous antibiotics until the symptoms subside. 21 If a patient's symptoms worsen, reevaluation and imaging should be performed to rule out delayed perforation.…”

“…21,22 After ruling out perforation, patients are usually admitted for bowel rest and intravenous antibiotics until the symptoms subside. 21 If a patient's symptoms worsen, reevaluation and imaging should be performed to rule out delayed perforation. 21…”