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

A Delayed Splenic Tragedy Beyond the Scope of a Colonoscope: A Rare Find

Colonoscopy is considered a low-risk procedure worldwide. Complications include hemorrhage, bowel perforation, and splenic rupture on rare occasions. The incidence of splenic rupture estimates between 0.00005 and 0.017%. Due to its nonspecific presentation, many cases may be misdiagnosed. We present a 76-year-old female on apixaban for atrial fibrillation who presented to us with sudden-onset, left-sided atraumatic chest pain radiating to the left shoulder, 10/10 in intensity, associated with nausea. The patient underwent an uncomplicated colonoscopy 16 days earlier with the excision of a 1.3 cm polyp. On presentation, her blood pressure was 96/58 mmHg, hemoglobin of 7.2, an international normalized ratio (INR) of 1.6. An abdominal computed tomography scan showed findings suspicious for splenic rupture. In the emergency department, two packed red blood cells (PRBCs) were transfused, and the patient was shifted to the operating room for emergent exploratory laparotomy where a splenectomy was performed for splenic rupture. The patient was discharged six days later without any postoperative complications. We speculate the use of apixaban and our patient's unusual site of pain following splenic rupture to be somehow correlated.

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.

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.

A register-based study: adverse events in colonoscopies performed in Sweden 2001-2013

OBJECTIVES

The rates for colonoscopy-associated adverse events vary considerably worldwide. In Sweden, the figures are known to a limited extent. We assessed the frequency of severe colonoscopy-related adverse events and the impacts of different risk factors, including the use of general anaesthesia.

MATERIAL AND METHODS

This is a retrospective population-based cohort study of the colonoscopies performed during the years 2001-2013 on adults identified in the Swedish health registers. The rates for bleeding, perforation, splenic injury and 30-day mortality were calculated. Covariates for risks were assessed in a multivariate Poisson regression model.

RESULTS

There were 593,315 colonoscopies performed on the 426,560 individuals included in the study. The rates for colonoscopy-related bleeding and perforation were 0.17% and 0.11%, respectively. When polypectomy was performed, the rates were 0.53% for bleeding and 0.25% for perforation. There were 31 splenic injuries (1:20,000 colonoscopies) reported. The crude 30-day death rate for colonoscopy was 0.68%. Of those diagnosed with bleeding or perforation, 5.6% and 6.1% were dead within 30 days, respectively. The multivariate RR for perforation when general anaesthesia was employed was 2.65 (p < .001; 95%CI 1.71-4.12).

CONCLUSIONS

The perforation rate seemed to be relatively high in an international perspective. General anaesthesia was associated with a significantly higher risk for perforation. Splenic injuries were more frequent than expected.

Death due to a rare complication of colonoscopy and the potential medicolegal implications

A 64-year-old woman was found dead at home after undergoing a screening colonoscopy. At autopsy, 1.9 L of blood was discovered within her abdominal cavity. The only major abnormality was nontraumatic avulsion of the splenic capsule. This was the only identifiable abnormality capable of causing the severe hemoperitoneum and demise of the patient. Although rare, splenic capsule avulsion is a recognized complication of colonoscopy. Many have theorized that it results from excessive traction on the splenocolic ligament resulting in a tear of the splenic capsule. Most patients present within the first 24 hours after the procedure with nonspecific symptoms, and many patients may not seek medical attention. The paucity of the literature in the area of splenic capsular avulsion after colonoscopy reinforces the importance of reporting known cases, and by doing so raise awareness of this rare but devastating complication of an otherwise beneficial screening procedure.

Iatrogenic splenic injury: review of the literature and medico-legal issues

INTRODUCTION

Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.

A systematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management

INTRODUCTION

Although uncommon, the incidence of splenic injury from colonoscopy has been increasing significantly since first being reported in 1974. Early recognition is critical because mortality may be as high as 5%.

METHODS

We systematically searched PubMed and EMBASE to identify English-language cases of splenic injury from colonoscopy from inception until January 26, 2015. We used descriptive statistics to characterize the identified cases.

RESULTS

A total of 172 cases from 122 reports were included. The mean age was 64 years and 70.8% were females. Prior abdominal or pelvic surgeries were identified in 63.8%. 57.3% of patients underwent polypectomies or biopsies. There was a statistically significant increase in use of computerized tomography for diagnosis in the past 5 years (81.8% versus 65.2%). 76.1% patients received transfusions. Mean inpatient length of stay was 7.83 ± 5.32 days. A non-significant trend toward conservative management was noted in the past 5 years (37.7% versus 23.1%), and a non-significant drop in mortality was noted (4.9% versus 5.4%).

DISCUSSION

Our data support prior literature suggesting a higher incidence of splenic injuries during colonoscopies in females, advanced age, prior history of abdominal/pelvic surgeries and biopsies/polypectomies during the procedure.

CONCLUSIONS

Significant mortality associated with splenic injuries during colonoscopies warrants prompt recognition of this potentially life threatening, albeit uncommon, complication.