Colonoscopy-induced splenic trauma: Strive for conservative management

Surgical Rounds®, December 2007, Volume 0, Issue 0

Nagesh B. Ravipati, Instructor/Chief Resident in General Surgery, Division of General Surgery; Mark C. Mason, Resident in General Surgery, Division of General Surgery; Lisa E. McMahan, Chief Resident in General Surgery, Division of General Surgery; Barbara A. Pockaj, Associate Professor of Surgery, Division of General Surgery; Lucinda A. Harris, Assistant Professor of Medicine, Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ

Nagesh B. Ravipati, MBBS

Instructor/Chief Resident

in General Surgery

Division of General

Surgery

Mark C. Mason, MD

Resident in General

Surgery

Division of General

Surgery

Lisa E. McMahan, MD

Chief Resident in

General Surgery

Division of General

Surgery

Barbara A. Pockaj, MD

Associate Professor of

Surgery

Division of General

Surgery

Lucinda A. Harris, MD

Assistant Professor of

Medicine

Division of

Gastroenterology

Mayo Clinic Arizona

Scottsdale, AZ

Introduction: Splenic trauma is a rare and potentially fatal complication of colonoscopy. Surgical treatment is required in many cases, but conservative management should be used when possible.

Results and discussion: The authors report a case of splenic trauma secondary to colonoscopy in an elderly women who was successfully treated conservatively. They also detail other cases reported in the literature and discuss the risk factors for splenic injury and the benefits of using a conservative approach.

Conclusion: Splenic trauma should be suspected in every patient who presents with abdominal pain following colonoscopy, especially those who are hemodynamically unstable or demonstrate an acute drop in hematocrit level. In cases where splenic trauma is identified early, the success rate of nonoperative treatment is increased considerably.

Colonoscopy is one of the most commonly performed procedures, and an estimated 14.2 million were undertaken in the United States in 2002.1 Although complications are rare, the most feared and fatal are perforation and hemorrhage, which have a reported incidence of 0.029% to 0.72% and 0.2% to 2.67%, respectively.2 Colonoscopy-induced trauma to the spleen was first reported in the literature approximately 30 years ago, but it is unusual. Approximately 45 cases have been reported in the literature.3,4 We report a case of splenic trauma from colonoscopy that was managed successfully using conservative treatment.

Case report

A 71-year-old woman who had undergone colonoscopic polypectomy of tubular adenomas several years earlier underwent a follow-up colonoscopy. Shortly after returning home, she experienced progressively worsening epigastric and left upper quadrant abdominal pain. She took ranitidine, but it failed to relieve her symptoms and she presented to the emergency department within 6 hours of the colonoscopy. She rated her epigastric and left upper quadrant abdominal pain as 10 on a scale of 0 to 10 and noted that the pain radiated to her left shoulder, which is known as Kehr's sign. The patient reported no nausea, vomiting, chest pain, or shortness of breath. She denied experiencing any recent falls or trauma. Her medical history was significant for rheumatoid arthritis, osteoporosis, and a bicuspid aortic valve. She took 3 mg daily of prednisone as well as adalimumab once every 2 weeks to treat her rheumatoid arthritis. She had no previous abdominal surgeries.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

The patient's vital signs were stableon physical examination, with a temperature of 36.6°C, pulse of 68 beats per minute, blood pressure of 147/81 mm Hg, respiratory rate of 24 breaths per minute, and oxygen saturation of 96% on room air. Her abdomen was nondistended and without rebound tenderness, but epigastric and left upper quadrant abdominal tenderness with some guarding was elicited on palpation. She had positive bowel sounds on auscultation. Laboratory studies demonstrated a white blood cell count of 7.2 x109/L (normal, 4.5—11.0 x109/L); hemoglobin of 12.7 g/dL (normal, 12.0—15.0 g/dL), which had dropped from 13.2 g/dL 2 weeks earlier; platelet count of 280 x109/L (normal, 150—450 x109/L); and a hematocrit of 37.2% (normal, 35%—45%). Cardiac enzymes and electrocardiogram results were normal. An abdominal computed tomography (CT) scan showed a splenic tear with a perisplenic hematoma and what appeared to be a small area of active bleeding (Figure).

The patient was admitted to the hospital for close clinical monitoring and serial hemoglobin checks. The following day, her hemoglobin and hematocrit dropped to 11.2 g/dL and 32.9%, respectively, but she remained hemodynamically stable. A repeat abdominal CT scan revealed no increase in the size of her splenic hematoma and no active bleeding. She was given morphine as needed for pain, and her hospital course was otherwise uneventful. She remained hospitalized for 3 days before being discharged. At 3-week follow-up, the patient was doing well and reported no problems.

A

B

Figure—CT scans showing the splenic injury with a perisplenic hematoma (A) and a small area of active bleeding, as demonstrated by the contrast blush (B).

Discussion

Splenic rupture is an extremely rare and potentially fatal complication of colonoscopy. Many physicians do not realize that this procedure can result in splenic injury. Most colonoscopy-related splenic injuries have been reported after apparently "easy" colonoscopies; therefore, making the diagnosis requires a high index of suspicion.

Risk factors for splenic injuryThe first case of splenic rupture from colonoscopy was reported by Wherry and Zehner in 1974 (Table).5-41 The presumed mechanism of splenic injury during colonoscopy is excessive traction on the colon and the splenocolic ligaments, which results in capsular avulsions and direct trauma. Certain colonoscopic techniques, such as the "slide-by" maneuver and "hooking," may contribute to splenic injuries by causing excessive traction. Another potential danger for the patient is when the endoscopist applies outer pressure on the left hypochondrium to straighten the splenic flexure.27 Factors that predispose patients to splenocolic adhesions, such as previous abdominal surgery, inflammatory bowel disease, and pancreatitis, are also risk factors for splenic injury.22 Splenomegaly and anticoagulation may increase the risk of splenic bleeding.9,42

Diagnosing colonoscopy-relatedsplenic injurySigns and symptoms of colonoscopy-related splenic injury mirror those of other splenic injuries associated with intra-abdominal bleeding. Most patients present within 24 hours following the colonoscopy, but it is not uncommon for patients to present after as many as 48 hours.24 The most common symptom is abdominal pain.12 Splenic injury should be suspected in every patient who reports experiencing abdominal pain following colonoscopy and especially in those who demonstrate hemodynamic instability or an acute drop in hematocrit level.

After an erect chest radiograph is performed to rule out perforation, CT scanning should be used. CT scanning is the diagnostic modality of choice because it is highly accurate in depicting splenic injuries and their severity. It may also show active bleeding (contrast blush).

No reports in the literature link the use of immunosuppressive agents such as prednisone and adalimumab with an increased risk of splenic injury at the time of colonoscopy or surgery. Theoretically, the prolonged use of prednisone is associated with the destruction of the collagen support for small blood vessels, which results in easy bruisability.43 The combination of prolonged prednisone use and the very acute angle of our patient's splenic flexure may have increased her risk of this rare complication.

Every attempt should be made to diagnose splenic injuries from colonoscopy promptly. This increases the patient's chances of remaining stable, which facilitates nonoperative treatment.

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Table. .

Managing colonoscopy-inducedsplenic injuries

Colonoscopy-induced splenic rupture is managed similarly to splenic injuries that result from trauma. Every effort should be made to treat the patient nonoperatively, with close clinical monitoring, serial hemoglobin evaluations, and the administration of blood product transfusions, as required. One reported case of splenic rupture after colonoscopy was treated using selective splenic artery embolization.31 A benefit of conservative management is that it eliminates the risk of overwhelming postsplenectomy sepsis, which occurs in 1% of adults who undergo splenectomy.44 The failure rate of conservative management is low, with approximately 10% of patients ultimately requiring surgical treatment.45

Conclusion

Splenic rupture is a rare and potentially fatal complication of colonoscopy that can be managed conservatively or surgically. Physicians should strive for a conservative approach to prevent the morbidity and mortality associated with surgery, such as overwhelming postsplenectomy infection. Because nonoperative treatment is most successful in patients whose injuries are identified quickly, splenic trauma should be suspected in every patient presenting with abdominal pain after colonoscopy.

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