Splenic rupture following colonoscopy

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.

Splenic Injury After Colonoscopy in a 55-Year-Old Female Patient

Colonoscopy is, in general, a relatively safe procedure with a low complication rate. Splenic injury related to this procedure is very rare, ranging from one in 100,000 to one in 6,387 colonoscopies, but a possibly lethal complication. For its diagnosis, a high degree of clinical suspicion is needed as many physicians are not aware of its existence. Clinical symptoms and signs are observed 1-10 days after the procedure. The imaging modality of choice is contrast-enhanced computed tomography (CECT). However, contrast-enhanced ultrasound (CEUS) may also be used to detect abdominal fluid and the injured area of the spleen. We present a case of a 55-year-old female with splenic rupture after a colonoscopy, diagnosed with CEUS and CECT. Splenectomy was performed, and the patient's recovery was uneventful.

Splenic rupture after colonoscopy for colorectal cancer screening

Colonoscopy is a frequently used procedure in our environment for the diagnosis, treatment and even prevention of colorectal cancer. Despite being a routine procedure, it is not exempt from possible complications. Bleeding and perforation are the main ones, with splenic rupture being extremely infrequent as well as one of the most serious complications derived from performing a colonoscopy. We present a patient with splenic rupture secondary to colorectal cancer screening colonoscopy who required urgent surgery for acute hemorrhagic shock.

Hemoperitoneum due to splenic injury after colonoscopy-Perhaps not a so uncommon a complication

We have read with interest in your journal the article "Splenic rupture as an endoscopic complication: as rare as it appears?" and we would like to contribute a case handled in our hospital. We present the case of a 72-year-old male smokerto whom an elective colonoscopy was performed with conscious sedation (midazolam and pethidine). The bowel preparation was appropriate. Diverticula and several pedunculated polyps were observed.

Acute colonoscopy-induced splenic rupture presenting to the emergency department

Splenic rupture due to colonoscopy is a rarely reported event in the emergency medicine literature. Patients experiencing such an occurrence are likely to report to the emergency department. This paper documents an 84-year-old female who presented to the emergency department with abdominal pain and nausea less than 24 hours following a colonoscopy. An abdominal ultrasound revealed splenomegaly and free fluid. An abdominal computed tomography was significant for a splenic laceration. She underwent radiologic guided embolization and recovered without incident. Emergency medicine physicians need to consider splenic rupture as a differential in patients presenting after colonoscopy with abdominal pain.

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

PURPOSE

Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures.

METHODS

We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared.

RESULTS

All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8 %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74 %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44 %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST.

CONCLUSION

We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

BACKGROUND

Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion.

METHODS

Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.

RESULTS

We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy.

CONCLUSIONS

Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

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 injury after colonoscopy: case report and review of literature

BACKGROUND

Splenic injury as a result of colonoscopy is rare but may be underreported and cases may remain undetected.

METHODS

Review of the literature and analysis of 93 cases, including a new case report.

RESULTS

Neither a history of abdominal surgery nor performance of a biopsy seems related to an increased incidence of splenic injury. However, a number of colonoscopy-related factors, such as difficulty intubating, looping of the instrument, and traction on the splenocolic ligament, lead to capsular avulsions and lacerations of the spleen. In addition, excess external pressure on the left hypochondrium can simulate blunt trauma, and other maneuvers can increase traction at the splenic flexure. In the majority of cases, symptoms develop within 24 hours of the colonoscopy. Computed tomography scan provides the most sensitive and specific method of diagnosis.

CONCLUSION

The number of colonoscopies continues to increase with the aging population, increasing the potential number of associated splenic injuries. The physician needs to have a high index of suspicion when a patient presents after colonoscopy with abdominal pain associated with hemodynamic instability. Abdominal pain within 24 hours is the most reliable indicator and requires further workup and monitoring. Persistent hemodynamic instability mandates operative management.

Two rare cases of spontaneous splenic rupture

The rupture of the spleen, not secondary to external trauma, is rare. Two cases are reported. The first case occurred in a patient with an aggressive form of lymphoma, and the second in a patient following a colonoscopy. In the rare occurrences of spontaneous rupture, radiological imaging, in particular by computed tomography, will lead to the diagnosis and help in deciding the correct treatment.

Splenic rupture: a case of massive hemoperitoneum following therapeutic colonoscopy

Colonoscopies are usually regarded as safe procedures with low complication rates and are recommended for anyone over the age of fifty for colon cancer screening. Splenic rupture is a rare complication of colonoscopy with few reported cases in the English literature. We present the only reported case of such a complication in the state of Hawai'i and the 44th reported case in the English literature. Physicians need to be more aware of the possibility of splenic rupture following colonoscopy to avoid delay of diagnosis and treatment of this life-threatening complication.