Rahul B. Chaudhari, MD, MRCP, Frederick Nunes, MD, FACG; Pennsylvania Hospital, Philadelphia, PA
Introduction: Splenic injury is a rare complication of colonoscopy that was first reported by Wherry et al in 1974. The true incidence remains unknown; however, it is estimated to be at 0.004%. It requires a high degree of suspicion and should be considered in patients having out of proportion abdominal pain, especially in the left upper abdomen or left shoulder, after colonoscopy.
Methods: A 58-year-old relatively healthy female underwent a screening colonoscopy. Following the procedure, she started having left upper quadrant abdominal pain, which did not improve after passing gas and walking around. The pain was positional and was relieved by leaning forward. Her vitals were stable, and abdomen was soft without any rebound or guarding. Due to no improvement over the next few hours, a CT abdomen with contrast was ordered which showed a small volume of peri-splenic-predominant, a small volume of hemoperitoneum; without splenic parenchymal abnormality or pneumoperitoneum. Her symptoms remained unchanged and she was observed for a few hours. She was discharged home without any surgical intervention. Her pain persisted for a month. A repeat CT abdomen after a month showed complete resolution of the peri-splenic bleed. The abdominal pain resolved completely after a month. Discussion: Splenic injury as a complication of colonoscopy is underdiagnosed and under-reported. It occurs more often in women. Risk factors include inappropriate intestinal preparation, antiplatelet/anticoagulant use, older age, previous splenic disease, redundant colon, intra-abdominal adhesions, excess traction, and deep sedation from propofol. Passage of endoscope through the splenic flexure causing direct trauma, traction on the spleno-colic ligament and traction on adhesion between spleen and colon causing rupture of the capsule are the major mechanisms of injury. The splenic injury can remain asymptomatic, however, the splenic rupture has significant morbidity and mortality. Patients can present early(within 48 hours) or late up to 2-10 days after the procedure. CT scan of the abdomen is the gold standard diagnostic tool, however, ultrasound can be useful in an emergency condition. Management depends on the extent of the injury and hemodynamic status of the patient and can involve surgical splenectomy, radiology guided selective splenic artery embolization or conservative. The suggested ways to minimize splenic injury are to keep the patient in the left lateral position, avoid supine position and avoid external pressure.
CT Abdomen with contrast immediately after colonoscopy showing the peri-splenic bleed
CT abdomen with contrast 1 month after the colonoscopy with complete resolution of the peri-splenic bleed
Disclosures: Rahul Chaudhari indicated no relevant financial relationships. Frederick Nunes indicated no relevant financial relationships.