Splenic rupture from colonoscopy. A report of two cases and review of the literature

Splenic artery embolisation for splenic injury during colonoscopy: A systematic review

BACKGROUND

Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.

METHODS

A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.

RESULTS

The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).

CONCLUSIONS

Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

Emergency splenectomy postelective colonoscopy

Colonoscopy is the gold standard for investigation of colorectal carcinoma and inflammatory bowel disease. Splenic injury is a rare but potentially fatal complication of colonoscopy. The present case study outlines the early clinical presentation and rapid deterioration of a patient with a splenic injury after an elective colonoscopy. A 70-year-old female underwent a colonoscopy for investigation of altered bowel habit. The procedure was documented as difficult due to the presence of 'stiff loopy colon'. In recovery, patient's condition deteriorated and she was moved to the ward for further assessment. She gradually became haemodynamically unstable and displayed signs of peritoneal irritation. Initial attempts of fluid resuscitation failed to improve patient's clinical condition. Further testing revealed a significant drop in haemoglobin and CT confirmed the diagnosis of a splenic rupture. She underwent an emergency splenectomy that evening. Postoperatively she was managed in the high dependency unit.

Splenic injury following elective colonoscopy: a rare complication

Splenic injury is an extremely rare, yet serious, complication related to colonoscopy. So far, less than 80 cases have been reported worldwide since 1970. With the increasing use of colonoscopy, endoscopists, surgeons and radiologists are more likely to encounter this unusual complication. Increased splenocolic adhesions, splenomegaly or underlying splenic disease might, inter alia, constitute a predisposing factor. However, it might also occur in patients without significant adhesions or underlying splenic pathology. Patients with abdominal pain, hypotension and a fall in hematocrit without rectal bleeding after colonoscopy, should be suspected of having splenic injury. Most patients present with symptoms within 24 hours after colonoscopy, nevertheless, delayed presentations have been described as well. We report such a case of splenic injury secondary to colonoscopy. The patient was presented with hemorrhagic shock and abdominal pain following a colonoscopy which had taken place before 36 hours, an urgent splenectomy was required with successful outcome.

Laparascopic Splenectomy Due to Splenic Injury after Colonoscopy

Colonoscopy, which is routinely performed in diagnosis and treatment of colorectal disorders, is a reliable procedure. Its most frequent complications are bleeding and perforation. Splenic rupture is a very rarely met complication of colonoscopy, and delay in its diagnosis leads to increased morbidity and mortality. We presented a 69 years old female patient, who was diagnosed by computerized abdominal tomography, performed for her abdominal pain, which started following the colonoscopy. After 15 days of medical treatment and follow-up, laparoscopic splenectomy was performed one month after her colonoscopy. The patient was discharged on her 4(th) postoperative day, with uneventful recovery. In patients who have complaint of abdominal pain following colonoscopy, an intraabdominal pathological condition should be considered and computerized abdominal tomography should be performed. If there is no detected intraperitoneal bleeding, in other words, if there is a sub-capsular hematoma of the spleen, medical management by monitoring the vital signs may be preferred. Then, splenectomy should be performed at an appropriate time.

Splenic rupture following colonoscopy: Case report and literature review

INTRODUCTION

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for colorectal diseases. Although bleeding and perforation are most common complications, extra colonic or visceral injuries have been described. Splenic rupture is rare with few cases reported in current literature.

PRESENTATION OF CASE

We report the case of a 73-year old man who presented to surgical consultation 50h after colonoscopy. Clinical, laboratory and imaging findings were suggestive for haemoperitoneum. At surgery an almost complete splenic disruption was evident and urgent splenectomy was performed.

DISCUSSION

Splenic injury following colonoscopy is exceptional, probably related to instrumental looping with excessive traction on the splenocolic ligament. In patients with an early presentation a sudden onset of symptoms is the rule. By contrast a delayed presentation (>48h) is nonspecific and subtle with arduous diagnosis.

CONCLUSION

Awareness of this potential complication, high level of suspicion and prompt treatment are at the basis of better outcomes in such patients.

Laparoscopic splenectomy for traumatic splenic injury after screening colonoscopy

Colonoscopy is a widespread diagnostic and therapeutic procedure. The most common complications include bleeding and perforation. Splenic rupture following colonoscopy is rarely encountered and is most likely secondary to traction on the splenocolic ligament. Exploratory laparotomy and splenectomy is the most commonly employed therapeutic intervention for this injury reported in the literature. We present the case of a patient with this potentially fatal complication who was treated successfully at our institution. To our knowledge it is the first report in the literature of laparoscopic splenectomy as a successful minimally invasive treatment of splenic rupture following colonoscopy. The patient was a 62-year-old female who underwent screening colonoscopy with polypectomies at the cecum, descending colon and rectum. Immediately following the procedure she developed abdominal pain and had a syncopal episode. Clinical, laboratory and imaging findings were suggestive of hemoperitoneum and a ruptured spleen. A diagnostic laparoscopy was emergently performed and revealed a grade IV splenic laceration and hemoperitoneum. Laparoscopic splenectomy was completed safely and effectively. The patient's postoperative recovery was uneventful. We conclude that splenic rupture after colonoscopy is a rare but dangerous complication. A high index of suspicion is required to recognize it early. Awareness of this potential complication can lead to optimal patient outcome. Laparoscopic splenectomy may be a feasible treatment option.

Splenic injury during colonoscopy--a complication that warrants urgent attention

INTRODUCTION

Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small but significant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosis may be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensive review of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation and management of this rare but potentially life-threatening complication.

MATERIALS AND METHODS

A comprehensive literature search identified 102 patients worldwide, including patients from our experience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalized linear model for repeated measures to identify risk factors for this rare complication.

RESULTS

A total of 75 articles were identified and 102 patients were studied. The majority of the papers were in English (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reported after the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %), median age was 65 years (range, 29-90 years), and most of the colonoscopies were performed without difficulty (66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive tool for diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemoglobin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortality rate was 5 %.

CONCLUSION

Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality. Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation is warranted.

Medico-legal considerations in a case of splenic injury that occurred during colonoscopy

Colonoscopy has became the gold standard diagnostic and therapeutic treatment for rectum and colon diseases. The splenic injury is a rare complication of colonoscopy and relatively few cases (less than 70) have been reported in the literature so far. Here we present a case of splenic rupture identified in an 80 year-old man few hours after an apparently uneventful colonoscopy. Acknowledging a causal relationship between the lesion and the diagnostic procedures, we discuss the possible medico-legal implications with regard to professional liability considering the exceptional nature of such an event and the stance recently taken by the Italian law.

Splenic rupture after screening colonoscopy: case report and literature review

Splenic rupture is a rare complication after colonoscopy, and to date there are only 46 reported cases in the English-language literature. Presented is a case report of splenic rupture after screening colonoscopy that resulted in laparotomy and splenectomy within 24 hours of the original procedure. The article covers the hypothesized mechanisms of injury, various precautions to take during colonoscopy, suggested diagnostic algorithm, determining factors in treatment, and vaccine regimen. The article concludes by stating that as the number of colonoscopies increase, so will the prevalence of associated complications, and that physicians are encouraged to understand this paradigm shift.

Splenic injury due to colonoscopy: analysis of the world literature, a new case report, and recommendations for management

Splenic injury is a rare complication of colonoscopy. Most literature on the topic is case-report based. Our objective was to perform a comprehensive analysis of characteristics of splenic injury due to colonoscopy from available published reports in the world literature, to compare and contrast this entity with that of traumatic splenic injury, and provide recommendations for management based on the analysis. We reviewed the PubMed database without restrictions using the terms splenic trauma after colonoscopy, splenic rupture from colonoscopy, splenic injury following colonoscopy, and splenic complications of colonoscopy, and also reviewed the references from the resulting publications. Retrieved manuscripts (case reports, reviews, and abstracts) were reviewed by two authors, and data extracted for 15 specific characteristics of each patient reported using a standardized data collection tool. Data were analyzed using descriptive statistics. Splenic injury due to colonoscopy is extremely rare as reported in published literature. The majority of patients that seek medical attention have delayed symptoms, and most require splenectomy. Subcapsular hematoma is the most common injury pattern seen. Selection criteria for operative management may be extrapolated from management guidelines for traumatic splenic injury, although nonoperative failure rates are higher for splenic injury due to colonoscopy than for trauma.

Splenic laceration following routine colonoscopy

Colonoscopy is a routine procedure done tens of thousands of times per year for screening purposes. The vast majority of these procedures are uneventful. There are, however, complications that can arise from this procedure, including hollow viscus perforation and hemorrhage. We present a case in which a lesser known complication of colonoscopy-splenic laceration-was cared for in our emergency department. This complication is unusual and not often cited in the literature, but is important to recognize and treat quickly. We present a case of a 67-year-old female who underwent a routine screening colonoscopy at our institution and presented to the emergency department several hours later complaining of abdominal pain. Ultimately, abdominal computed tomography showed a large splenic laceration, which was treated operatively. The diagnosis of splenic laceration should be considered for patients with continued abdominal pain post-colonoscopy when other etiologies have been evaluated and ruled out.

Splenic rupture as a complication of colonoscopy: report of a case

Colonoscopy is a common procedure with the rare complication of a splenic injury. The proposed mechanism of injury is excessive splenocolic ligament traction. The diagnosis is made by computed tomography and the treatment is determined by the patient's stability. Here we report a case of splenic injury during colonoscopy with failure to manage conservatively. A review of the literature and suggested guidelines are also provided.

Colonoscopic splenic injuries: incidence and management

PURPOSE

Splenic injuries that occur during colonoscopies are rare. There is no available incidence of this serious complication, and the literature is limited to case reports. Our study looks at single institution experience of splenic injuries during colonoscopy to define the incidence and management of this serious complication.

METHODS

All patients from 1980 through June 2008 sustaining a splenic injury during colonoscopy were reviewed.

RESULTS

Four patients (of 296,248 colonoscopies) sustained a splenic injury directly from colonoscopy performed at our institution (incidence 0.001%). Three additional patients were treated at our tertiary referral center after splenic injury from colonoscopy performed elsewhere. The mean age at the time of colonoscopy was 54 years (range 40-70 years). The most common presenting symptom was abdominal pain (n = 4) with a mean decrease in hemoglobin of 6.5 g/dl (range 4.5-8.5 g/dl). Splenic injury was diagnosed by computed tomography in five patients. Six patients received a mean of 5.5 U of packed red blood cells (range 2-14 U). All patients were managed with splenectomy, six patients within 24 h of the index colonoscopy, and one patient presented more than 24 h after initial colonoscopy. There was no evidence of preexisting splenic disease in any of the patients by surgical pathology, and there were no postoperative complications or deaths. The mean duration of stay was 10 days (range 7-15 days). All patients are alive at a median follow up of 22 months (range 1-164 months).

CONCLUSION

Splenic injury occurring during colonoscopy is a rare but serious complication. Patients presented with abdominal pain and a precipitous decrease in hemoglobin and have all required emergent splenectomy.

Splenic rupture after colonoscopy: a case report

Iatrogenic splenic tear after a colonoscopy is a rare complication. Conditions predisposing to splenocolic adhesions such as previous abdominal surgery, pancreatitis, or inflammatory bowel disease may increase the risk of this injury after colonoscopy. We present a case of a 47-year-old woman with an iatrogenic splenic tear after a routine colonoscopy, who had several of these predisposing factors and required an urgent splenectomy.

Splenic injury following colonoscopy--an underdiagnosed, but soon to increase, phenomenon?

INTRODUCTION

We present a case of splenic rupture in a 71-year-old woman admitted 6 days following a diagnostic colonoscopy. She underwent an open splenectomy and made a delayed, but complete, recovery. We proceeded to perform a retrospective review of all relevant literature to assess the frequency of similar post-colonoscopy complications.

MATERIALS AND METHODS

Using relevant keywords, we identified 63 further PubMed reports of splenic injury associated with colonoscopy that were reported in English.

FINDINGS

We have described only the fourth report of splenic injury secondary to colonoscopy from a UK centre. Literature review reveals a mean age of 63 years and a female preponderance for this complication. Most patients present on the day of their colonoscopy with abdominal pain, anaemia, elevated white cell count and Kehr's sign. CT is the investigation of choice and splenectomy the definitive management of choice. Most patients make a routine recovery, with mortality rates of approximately 8%. There is likely to be an under-reporting of this complication from UK-based centres, with the majority of reports originating from Europe and US. This points to a possible under-diagnosis or under-recognition of this potentially fatal complication. The incidence of such post-colonoscopic complications may increase with the forthcoming introduction of the National Bowel Cancer Screening Programme.

Splenic injury in colonoscopy: a review

INTRODUCTION

Splenic rupture secondary to colonoscopy was first reported in 1974 by Wherry and Zehner. It has an incidence of around 0.00005-0.017%, and a mortality rate of 5%.

METHOD

We performed a literature search to identify the demographic profile, risk factors, clinical presentations, diagnosis and management of this rare complication.

RESULTS

There were 66 patients (51 females and 14 males), with a median age of 65. The mortality rate was 4.5%. Majority (n=41, 62.1%) occurred in uneventful colonoscopies. Symptoms usually (74%) occurred within 24h, and 55.8% presented within 24h. Majority (93.9%) had some form of work-up done, with blood tests (78.8%) and CT (68.2%) being the most frequent. Laparotomy and splenectomy were done in over half (56.1%) of the patients. Splenic hematoma (47%), laceration (47%) and rupture (33.3%) were the most common findings.

CONCLUSION

Splenic injury is an important complication to be aware of as its number will continue to rise with the increasing numbers of colonoscopies being performed for colorectal diseases, and delayed diagnosis may result in adverse outcome for the patient.

Splenic rupture following colonoscopy

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for different colorectal diseases. Although the most common complications are bleeding and perforation, extracolonic or visceral injuries have also been described. Splenic rupture is a rare complication following colonoscopy, with few cases reported. We report a 60-year-old female who presented to surgical consultation 8 h after a diagnostic colonoscopy. Clinical, laboratory and imaging findings were suggestive for a massive hemoperitoneum. At surgery, an almost complete splenic disruption was evident, and an urgent splenectomy was performed. After an uneventful postoperative period, she was discharged home. Splenic injury following colonoscopy is considered infrequent. Direct trauma and excessive traction of the splenocolic ligament can explain the occurrence of this complication. Many times the diagnosis is delayed because the symptoms are due to colonic insufflation, so the most frequent treatment is an urgent splenectomy. A high index of suspicion needs an early diagnosis and adequate therapy.

Colonoscopy-induced splenic injury: report of 3 cases and literature review

BACKGROUND

Since its first report in 1974, 66 cases of splenic injury after colonoscopy have been reported in the world literature. Splenic injury is among the rarest complications of colonoscopy. However, it can be associated with severe morbidity and has rarely been fatal.

OBJECTIVES

Three cases of splenic injury following colonoscopy are described, and the world literature is reviewed.

METHODS

Case reports and literature review.

RESULTS

Seventy-six percent of the patients were females. When reported, colonoscope insertion was technically difficult in 36% of cases. The onset of symptoms is usually within 48 h of colonoscopy. Abdominal pain was the most common presenting symptom (93% of cases). CT scan and ultrasound each had 100% diagnostic sensitivity when performed. Twenty of 65 cases (31%) with available data were successfully managed supportively with bed rest, transfusion and pain control. Hemodynamic instability was associated with surgical treatment, but no clinical features were perfect predictors of successful conservative therapy or the need for surgery.

CONCLUSIONS

Splenic injury during and after colonoscopy is more common in women. Technically difficult colonoscopy is a possible risk factor. Onset of symptoms is often delayed by hours. CT scan is probably the best diagnostic test for splenic injury after colonoscopy, though the literature indicated ultrasound is also sensitive. Patients with hemodynamic instability are most often operated. Patients with confined intrasplenic hematoma and hemodynamic stability can be given a trial of conservative management.

Splenic rupture after colonoscopy: Report of a case and review of literature

Splenic rupture is a rare complication of colonoscopy. For this reason the diagnosis could be delayed and the outcome dismal. Fifty-four cases of splenic rupture after colonoscopy have been described in the literature. The majority of the cases required emergent or delayed splenectomy, 13 of these cases were treated conservatively. The main feature that stands out from the review of the literature is the "surprise" of this unexpected complication. This factor explains the elevated mortality (2 out of 54 cases), likely due to the delay in diagnosis. The case here described is probably among the most complex published in the literature; in fact the presence of dense intra-abdominal adhesions not only contributed to the complication itself, but also explain the confinement of the hemoperitoneum to the left supra-mesocolic space and the delayed presentation (13 days from the time of the trauma).

Iatrogenic Injury to the Spleen—CT Appearance

Splenic injury is a well-known but rare complication of various abdominal surgical and invasive procedures, and even of cardiac surgery. The true incidence of iatrogenic splenic trauma is, however, difficult to assess and is probably underestimated. Overt injuries diagnosed during surgery are usually immediately treated by splenectomy without imaging. This review focuses on missed splenic injuries that are diagnosed on imaging following surgery or an invasive procedure.

Splenic Rupture: An Unusual Complication of Colonoscopy

Splenic rupture after colonoscopy is rare. Only 44 cases previously have been reported in the English literature. Partial capsular avulsion is the proposed mechanism of injury. Any condition causing increased splenocolic adhesions may be a predisposing factor to splenic injury. One case of splenic injury after colonoscopy is reported in addition to a complete review of the literature.

Splenic rupture after diagnostic colonoscopy: a case report

Colonoscopy is a commonly used diagnostic and therapeutic procedure. Splenic injury or rupture after this procedure is rare. We report a case of splenic rupture and hematoma in a middle-aged man who presented with symptoms of worsened anemia after diagnostic colonoscopy.

Splenic rupture following colonoscopy: Rare in the UK?

Splenic injury following colonoscopy is rare, with only 28 cases reported so far in the English language literature. Direct trauma during colonoscopy or traction on the spleno-colic ligament is the proposed mechanism of injury. Computed tomography (CT) of the abdomen is usually considered to be the most sensitive and specific modality for diagnosis. We report a case of a 56-year-old female, who was diagnosed having a splenic rupture following a routine colonoscopy for investigation of anaemia. She underwent an emergency laparotomy with splenectomy and made a satisfactory recovery post-operatively. We wish to highlight that there should be a high index of suspicion of splenic rupture in patients presenting with abdominal pain and demonstrating a positive Kehr's sign following colonoscopy. Only two case reports from the United Kingdom have been published, raising the possibility of under-reporting of such cases.

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Delayed presentation of splenic rupture after colonoscopy

Splenic rupture is a rare but potentially deadly complication of colonoscopy. We present the case of a 70-year-old male who presented with abdominal pain, initially stable, almost 2 days after colonoscopy. The patient's clinical status deteriorated shortly after abdominal CT scan identified splenic rupture.