Endovascular treatment of active splenic bleeding after colonoscopy: a systematic review of the literature

Splenic rupture following endoscopic mucosal resection: A case report and literature review

RATIONALE

This study aims to highlight the rare but severe complication of splenic rupture following colorectal endoscopic mucosal resection (EMR), advocating for increased vigilance during procedures near the splenic flexure.

PATIENT CONCERNS

We present a case report of a 66-year-old woman who experienced persistent abdominal pain after undergoing EMR for an adenomatous lesion in the distal transverse colon.

DIAGNOSES

The diagnosis of splenic rupture was established following her symptoms and clinical evaluation.

INTERVENTIONS

Active conservative management was implemented after diagnosis.

OUTCOMES

The patient's recovery underscores the importance of prompt diagnosis and careful monitoring.

LESSONS

Although splenic rupture after EMR is extremely rare, it is a serious and potentially life-threatening complication. When obtaining informed consent, it is important to emphasize not only common complications like bleeding and perforation but also the risk of splenic injury. Physicians should select appropriate instruments and carefully adjust the angle and force of needle insertion, avoiding excessively long needles and vertical insertion. The procedure should be performed gently to minimize the risk of splenic rupture. For lesions near the splenic flexure, if postoperative abdominal pain occurs, regardless of left shoulder pain, splenic rupture should be considered, and a computed tomography scan promptly performed. Postoperatively, physicians should closely monitor vital signs and repeatedly check blood counts and coagulation parameters. Treatment should be tailored to the splenic injury's extent and the patient's overall condition, with immediate surgery if necessary. High-risk patients should be regularly followed up and instructed to monitor for physical changes. Endoscopists should remain vigilant during procedures, fully understanding potential complications, and closely monitoring the patient's condition postoperatively. This vigilance is key to preventing severe complications and ensuring optimal outcomes.

Moderate Splenic Injury Caused by Colonoscopy

Little is known about iatrogenic splenic injury (SI) as an adverse event after colonoscopy. SI is sometimes fatal because of hemorrhaging. We herein report a man who developed SI after colonoscopy. He recovered conservatively. His history of left hydronephrosis and insertion with a maximally stiffened scope were suspected as possible risk factors. Endoscopists should consider the possibility of SI when they encounter patients suffering from left-sided abdominal pain after colonoscopy. Careful interview concerning the medical history and gentle maneuvering around the splenic flexure can help avoid SI.

Splenic Injury After a Colonoscopy: Threading the Scope Carefully in Heritable Connective Tissue Disorders

Colonoscopies have reduced colorectal cancer (CRC) burden in the United States, and their utility has expanded to include various diagnostic and therapeutic indications. Complications are seen in up to 1% and increase with age and polypectomy. As colonoscopies become widespread, specific populations seem to be at a much higher risk; notably patients with heritable connective tissue disorders (HCTD). As life expectancy increases, these patients undergo routine screenings and require careful peri-endoscopic care to reduce adverse outcomes. Amongst HCTD, Ehlers-Danlos syndrome (EDS) is commonly implicated, however, no reports of Marfan syndrome (MS) exist. We present a unique case of splenic injury after colonoscopy in a patient with MS. Successful outcomes require early suspicion and emergent surgical evaluation in patients with hemodynamic instability after a colonoscopy. Increased ligament laxity and bowel fragility are the most likely mechanisms. Alternative CRC strategies like fecal immunochemical test (FIT), fecal occult, Cologuard, or virtual colonography can be considered.

Iatrogenic Severe Splenic Injury after Colonoscopy

Colonoscopy is a low-risk procedure performed for screening and diagnostic purposes. About 15 million colonoscopies were carried out in the United States in 2012 with this number projected to increase. Injury to the spleen as a complication of colonoscopy is still a rather rare occurrence. We report a case of significant splenic injury, American Association of Surgery for Trauma (AAST) grade III with hemoperitoneum, in a patient following diagnostic colonoscopy, managed conservatively without the need for invasive or salvage surgical procedure.

Splenic injuries secondary to colonoscopy: Rare but serious complication

BACKGROUND

Colonoscopy is a safe and routine diagnostic and therapeutic procedure for evaluation of large bowel diseases. Most common procedure related complications include bleeding and perforation but rarely a splenic Injury.

AIM

To investigate the reason for colonoscopy, presentation of patient with spleen injury, types of injury, diagnosis, management and outcomes of patients

METHODS

A structured search on four databases was done and 45 articles with 68 patients were selected. The reason for colonoscopy, presentation of patient with spleen injury, types of injury, diagnosis, management and outcomes of patients were identified and analyzed using SPSS.

RESULTS

The mean age of the patients was 62.7 years with 64% females. Twenty two percent had a complete splenic rupture with colonoscopy while 63% had subcapsular hematoma, spleen laceration and spleen avulsion. The most common reason for colonoscopy was screening (46%) followed by diagnostic colonoscopy (28%). Eighty seven percent of patients presented with abdominal pain. Patients with spleen rupture mostly required splenectomy (47%), while minor spleen hematomas and lacerations were managed conservatively (38%). Six percent of the patients were managed with proximal splenic artery splenic embolization and 4% were managed with laparoscopic repair. The overall mortality was 10% while 77% had complete recovery. The reason of colonoscopy against presentation specifically, abdominal pain showed no statistical significance P = 0.69. The indication of colonoscopy had no significant impact on incidence of splenic injury (P = 0.89). Majority of the patients (47%) were managed with splenectomy while the rest were managed conservatively (P = 0.04). This association was moderately strong at a cramer’s V test (0.34). The Fisher exact test showed a higher mortality with spleen rupture (P = 0.028).

CONCLUSION

Spleen rupture due to colonoscopy is a significant concern and is associated with high mortality. The management of the patients can be individualized based on clinical presentation.

Postcolonoscopy splenic rupture: the under-reporting of an unpropitious phenomena?

Splenic rupture secondary to colonoscopy is a rare but potentially fatal complication. Given the disparity between the small number of case reports with the incidence reported by some investigators, we contend that the former is not representative of the true extent of this sequela. We present a case report of postcolonoscopy splenic rupture, where the patient had a bizarre initial presentation of chest pain and collapse; and only developed haemodynamic instability and abdominal pain on day 2 postprocedure. Diagnosis was made with a CT scan, and resolution of symptoms was achieved with a splenectomy.

Splenic Trauma during Colonoscopy: The Role of Intra-Abdominal Adhesions

Splenic rupture following colonoscopy is rare, first reported in 1974, with incidence of 1–21/100,000. It is critical to anticipate splenic trauma during colonoscopy as one of the causes of abdominal pain after colonoscopy especially when located in the left upper quadrant or left shoulder. Postoperative adhesions is a predisposing factor for splenic injury, and management is either operative or nonoperative, based on hemodynamic stability and/or extravasation which can be seen on contrast-enhanced CT scan of the abdomen. We present a case of a splenic rupture after colonoscopy in a patient with splenocolic adhesions, requiring splenectomy as definite treatment.

A rare complication after colonoscopy: a splenic rupture

Colonoscopy is the gold standard for the study of colorectal pathology. Splenic injury is a rare but potentially fatal complication to consider. Therefore, we present two cases whose management was different and we show their clinical presentation, their diagnosis and their treatment in order to recognize this complication early to establish early treatment.

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.

Shock due to Splenic Injury after Colonoscopy

Colonoscopy is a common and increasingly performed procedure. It is used both as a diagnostic and therapeutic modality. Splenic injury after colonoscopy is a rare, yet life-threatening complication, most often caused by traction on the splenocolic ligament or excessive manipulation during the procedure. Although non-operative treatment is preferred upon splenic injury, early surgical or radiological intervention may be necessary in specific cases, for example in case of haemodynamic instability. A 71-year-old Caucasian man was referred to our emergency room due to shock after colonoscopy 2 days earlier. A computed tomography scan showed splenic rupture with active intra-abdominal, venous blood loss, and microperforation of the colon. An immediate splenectomy and colon repair were performed through laparotomy. After 6 days, the patient was discharged from hospital in good health. Although splenic rupture is a rare complication of colonoscopy, patients with abdominal pain and/or shock should be checked for complications such as splenic injury and colon perforation.

Splenic rupture after colorectal cancer screening

The number of colonoscopies performed in recent years is increasing dramatically, specially those related to colorectal cancer screening programmes. For this reason, there is a direct relationship with the number of exceptional complications such as splenic rupture. We describe a clinical case of a splenic rupture with hemodynamic instability. Consequently, an emergency splenectomy was performed 6 hours after the colonoscopy was finished. Health staff should be aware of its existence, as an early reaction will avoid more severe problems.

Colonoscopic Splenic Injury: A Simplified Radiologic Approach

Colonoscopy is a commonly performed procedure for diagnosis and treatment of large bowel diseases. Recognized complications include bleeding and perforation. Splenic injury during colonoscopy is a rare complication. We report a case of a 73-year-old woman who presented with left-sided abdominal pain after colonoscopy with finding of splenic injury on CT scan. She was managed conservatively. We discuss the diagnostic and therapeutic approach to colonoscopic splenic injury.

Splenic Rupture as a Complication of Colonoscopy

Splenic rupture is a rare but serious complication after colonoscopy, with high global mortality (5%). Diagnosis requires a high index of suspicion because presentation can be subtle, nonspecific, and delayed from hours to days and then not easily attributed to a recent endoscopy. Urgent splenectomy is the most common treatment option. A 73-year-old woman was admitted to the emergency department 8 h following a diagnostic colonoscopy. She presented abdominal pain and syncope. The diagnosis of splenic rupture was made and a splenectomy was urgently performed. The patient's postoperative recovery was uneventful. Splenic rupture is a rare complication of colonoscopy which cannot be underestimated in the differential diagnosis of abdominal pain after this procedure. Splenic injuries may occur in apparently uncomplicated, easy colonoscopies performed by experienced endoscopists, with no risk factors identified, as in this case.

Diagnosis and management of splenic injury following colonoscopy: algorithm and case series

BACKGROUND

Splenic injury following colonoscopy is a rare yet life-threatening complication. These injuries are often associated with delayed diagnosis and may require invasive intervention. We sought to study the emergent presentation associated with splenic injury post-colonoscopy and to suggest a new treatment algorithm.

METHODS

Six cases of splenic injury following colonoscopy were collected from three medical centers. Data regarding patient medical history, clinical presentation, laboratory and imaging findings and clinical management were recorded. A systematic PubMed/MEDLINE search was performed. Non-English-language publications and publications dating earlier than 2010 were excluded. An emergency department trauma-based management algorithm was designed according to the identified publications and review of the available trauma literature.

RESULTS

The mean age was 65.3 years and the male-to-female ratio was 1:5. Five of the cases presented within 24 h of the colonoscopy complaining of severe abdominal pain. Hemodynamic instability was noted in four patients who presented with tachycardia (105-130), hypotension and/or a rapid drop in hemoglobin levels. All of the patients underwent initial resuscitation and a computerized abdominal tomography scan. Four of them required emergent splenectomy. No mortality or major morbidity was reported following the hospitalization.

CONCLUSIONS

Although very rare, splenic injury during colonoscopy is an acute, severe and possible fatal complication. Patients may present with a rapid clinical deterioration and hemodynamic instability. Physicians should be familiar with the practical management of this surgical emergency and the treatment options available.

Superselective splenic artery embolization for the management of splenic laceration following colonoscopy

Splenic injury is a rare complication following colonoscopy with fewer than 100 reported cases worldwide to date. We describe a case of splenic laceration presenting 5 days following diagnostic colonoscopy. Although hemodynamically stable, active contrast extravasation on contrast-enhanced multidetector computed tomography predicted likely failure of conservative management. Splenic artery angiography confirmed active extravasation from the lower splenic pole and the patient was successfully treated with super selective coil embolization of a lower pole splenic artery branch. This is the eighth reported case of endovascular treatment of splenic injury following colonoscopy. To our knowledge, however, superselective splenic artery embolization has not been previously reported to treat this rare endoscopic complication.