Smit S. Deliwala, MD1, Brandon T. Wiggins, DO, MPH2, Cassandra A. LaMarche, BSc3, Rohit Gupta, MD4, Ghassan Bachuwa, MD, MS4, Mark J. Minaudo, DO2 1Michigan State University at Hurley Medical Center, Flint, MI; 2Ascension Genesys Hospital, Grand Blanc, MI; 3Michigan State University College of Human Medicine, East Lansing, MI; 4Hurley Medical Center, Flint, MI
Introduction: Splenic injuries occur at 0.20 per 10,000 colonoscopies with a high mortality rate. Risk factors such as age, female sex, splenomegaly, adhesions from prior surgeries, malignancy, sepsis, polypectomy, or ongoing anticoagulation have been established. Marfan syndrome (MS), is one of the more common heritable connective tissue disorders (HCTDs). As life expectancy and survival increase, they are poised to undergo standard health screenings. HCTD pose a substantial risk to gastroenterology practices for spontaneous and instrumentation-related injuries and many remain undiagnosed for years. Data is sparse, emphasizing case reports to guide management.
Case Description/Methods: 75 yo male presented to our ED with abdominal pain, nausea, weakness, malaise, diarrhea. History of MS, COPD, hypertension, AAA with open repair, EVAR, TAVR, and a bypass for PAD. He received a colonoscopy the previous day and three sessile polyps between 0.75 cm – 1.25 cm were removed (1x cold snare, 2x hot snare) [Figure 1 - Pane A,B]. On arrival, he was unstable appeared ill and frail. On exam, murmur, bruising and abdomen was diffusely tender with hypoactive sounds. Hgb - 6.7, PLT 62, lactic acid 8.92, glucose 200, and renal failure. Despite IV fluids, he required vasopressors and a massive transfusion. He was made NPO and started on antibiotics. CT abdomen revealed widespread hematoma and rupture [Pane C,D]. Shortly after, he was taken to the operating room (OR) for an emergency exploratory laparotomy and had an uneventful recovery.
Discussion: A recent study found HCTD to be significantly associated with perforations with more events than cancer, renal, pulmonary, vascular disease, or ongoing anticoagulation. Patients with HCTD are at a higher risk for instrumentation-related injury, and this report emphasizes careful selection and pre-endoscopic assessment of these patients. Ligament laxity, a core feature of HCTD, can contribute to excessive stretching the ligament and rupturing blood vessels. Non-invasive screening and diagnosis methods should be considered when patients have a strong history of vascular fragility such as FIT, Cologuard, or CT colonography. Limitations include another rare entity involving the spleen known as “wandering spleen,” characterized by ligament weakness and the propensity to avulse itself as a differential. HCTD patients pose technical challenges due to increased tissue laxity and colonic distensibility, which may be improved by using colonoscopies with algorithms that improve stabilization.
Figure: Figure 1: Pane A,B - Colonoscopy revealing the identification of polyps and snare polypectomy. Pane C,D - Computed Tomography (CT) of the abdomen revealing hematoma in the sub-diaphragm, ligaments and around the liver extending into the pelvis with a ruptured splenic capsule (arrows).
Smit Deliwala indicated no relevant financial relationships.
Brandon Wiggins indicated no relevant financial relationships.
Cassandra LaMarche indicated no relevant financial relationships.
Rohit Gupta indicated no relevant financial relationships.
Ghassan Bachuwa indicated no relevant financial relationships.
Mark Minaudo indicated no relevant financial relationships.
Smit S. Deliwala, MD1, Brandon T. Wiggins, DO, MPH2, Cassandra A. LaMarche, BSc3, Rohit Gupta, MD4, Ghassan Bachuwa, MD, MS4, Mark J. Minaudo, DO2. P1483 - Splenic Infarct After a Colonoscopy: Thread Carefully in Heritable Connective Tissue Disorders (HCTD), ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.