Splenic Rupture After Colonoscopy: Case Report and Literature Review

Abstract

C olonoscopy has become an invaluable tool in the diagnosis and treatment of diseases of the colon and rectum. The most common complications are bleeding and perforation, which occur in up to one percent of patients undergoing diagnostic colonoscopy and three percent of patients undergoing therapeutic colonoscopy. 1 Less common complications include pneumothorax, pneumomediastinum, mesenteric tear and colonic volvulus. Splenic rupture is a rare colonoscopic complication, with only 24 cases reported in American literature 2-23 and 11 additional cases reported in foreign literature. 24 -34 The first case of splenic rupture resulting from colonoscopy was reported in 1974 by Wherry and Zhener. 2 We present our experience with a case of splenic rupture after colonoscopy in a 59-year-old woman managed without surgical intervention. CASE REPORTA 59-year-old white woman with a family history of colon cancer underwent a screening colonoscopy. Her surgical history included a total abdominal hysterectomy and a subsequent salpingo-oophorectomy. The colonoscopy was performed without difficulty. Diagnostic findings were a tortuous left colon, hemorrhoids and rare diverticuli. No polyps or cancer were seen. The post-sedation recovery was uneventful and the patient felt well with no complaints upon routine discharge.Five hours after discharge the patient developed severe left-sided abdominal pain that radiated to the tip of her left shoulder. At assessment in the emergency room her heart rate was 97 bpm and blood pressure 141/79 mm Hg. Bowel sounds were normal, abdomen soft and non-distended with generalized tenderness. Abdominal films revealed gas within a non-distended colon, but no free air present. The patient was resuscitated with IV fluids and admitted to the intensive care unit by the medicine serivce. The hemoglobin level decreased from 12.0 g/DL to 6.6g/DL at 20 hours after admission. A resultant progressive tachycardia and low systolic blood pressure accompanied the decreasing hemoglobin level resulting in surgical consultation. Computed tomography (CT) revealed a Grade II-III splenic injury with no active extravasation (Fig. 1). A 14.4 ϫ 9.6 cm splenic hematoma extended down the left pericolic gutter into the pelvis and the liver was surrounded with a moderate amount of low density fluid consistent with free blood.Four units of packed red blood cells were administered and within the first 24 hours vital signs normalized and serial hemoglobin tests showed no evidence of active bleeding. Because there was no active bleeding or free air, and the splenic injury was Grade II-III, non-operative management was continued. By 27 hours after admission, the hemoglobin stabilized at 12.1 g/DL and did not significantly decline for the remainder of her hospitalization. Partial resolution of the hemoperitoneum and subcapsular splenic hematoma were seen on a follow-up CT scan on the 9th day (Fig. 2). The patient continued to improve clinically and was discharged home on the 10th day.

Laparascopic Splenectomy Due to Splenic Injury after Colonoscopy

“…Therefore, we suggest that the incidence of splenic injury following colonoscopy is very low. Splenomegaly, adhesions related to previous operations, anticoagulant use, smoking, inflammatory bowel disease, difficult colonoscopy, intention to rush during the procedure, and insufficient visualization due to inadequate bowel cleansing are among predisposing factors for splenic injury [7,8]. However, there is no specific cause of splenic injury.…”

“…There are reports about cases managed by blood transfusions depending on the hemodynamic status of the patient, and broad-spectrum antibiotics [8,12]. Our patient was, primarily, treated conservatively with the purpose of hemodynamic stabilization, after that, laparoscopic splenectomy was performed.…”

Splenic rupture following colonoscopy

“…Only 40 cases have been reported [3][4][5][6][7][8][9][10][11][12][13][14][15] . To our knowledge, our case is the first case coming from South America.…”

“…In most series, splenectomy is the most frequent treatment of choice [3][4][5][6][7][8][9] . Very few cases have been treated with transfusion of hemocomponents, broad spectr um antibiotics and close hemodynamic monitoring [10,13,14] . Another therapeutic action successfully described is splenic artery embolization [15] .…”

“…A polypectomy or a biopsy was performed in most of reported cases [8] . Splenomegaly, inflammatory bowel disease, pancreatitis and intrabdominal post-surgical adhesions have been mentioned as predisposing factors, due to a suspected decreased mobility between the spleen and colon [8][9][10] .…”