Hemoperitoneum after routine colonoscopy: A case report

Abstract

Introduction and importance

Colonoscopy is a routine examination which is considered a safe and low risk procedure. Hemoperitoneum due to a splenic injury after colonoscopy is a rare but life-threatening complication.

Case presentation

We present the case of a 57-year-old woman without medical or surgical history who presented acute abdominal pain after a colonoscopy with three polypectomies. Clinical, biological investigations and imaging were suggestive for a hemoperitoneum. An emergency exploratory laparoscopy revealed a massive hemoperitoneum due to 2 avulsions of the splenic capsule.

Clinical discussion

We review the literature on incidence, mechanisms, risk factors, common symptoms, diagnosis methods and therapeutic options concerning hemoperitoneum due to a splenic injury after colonoscopy.

Conclusion

The early suspicion of this potential complication is the key to good care in this situation.

Highlights

• •Splenic injury after colonoscopy is rare but with potentially lethal consequences.
• •An early management allows decreasing mortality rate.
• •Acute abdominal pain is the most common symptom of splenic injury after colonoscopy.
• •Contrasted abdominal CT scan is considered the gold standard exam in this situation.

1. Introduction and importance

Diagnostic colonoscopy and therapeutic colonoscopy are a very common procedure in developed countries, as it represents the final stage of colorectal cancer screening. For example, it is performed around 1,3 million times in a year in France [1]. The global risk of complication after colonoscopy is estimated at 1.98 per 1000 examinations and the 2 most common complications are colic perforation and bleeding on polypectomy [2]^, [3]. Splenic injury after colonoscopy is rarer but potentially lethal, with incidence rates estimated between 0.000005 and 0.017 % [4]. In those cases, the mortality rate is estimated at 10 %. Because of its rarity, risks factors are not clearly identified and are still debated in literature [5]. Mechanisms of splenic damage are most probably an excessive traction on the spleno-colic ligament due to endoscope movement or direct trauma by the endoscope.

This work has been reported in line with the SCARE 2020 criteria [6].

2. Case presentation

We present the case of a 57-year-old woman without medical or surgical history that had a colonoscopy with resection of three polyps: two 5 mm sessile polyps of the transverse colon and a 10 mm sigmoid polyp were resected. The colonoscopy was carried out without any adverse events. 6–8 h after the colonoscopy, she developed acute abdominal pain, nausea, vomiting and vertigo. She had no fever, chills or any other complaint. On physical examination, she had a hypotension of 80/56 mmHg and a cardiac frequency of 64 bpm. She had a diffuse abdominal sensibility, more marked on the left flanc. Gazometry at this moment revealed 34 % of hematocrit, 11.7 g/dL of hemoglobin and no ionic anomalies. Lactate was 8 mg/dL. An abdominal CT scan without contrast was performed in emergency and revealed free fluid on the left flanc, from the spleen to the pelvis (Fig. 1.A–B–C). There was no evidence of pneumoperitoneum. An exploratory laparoscopy was performed immediately after. It revealed a massive hemoperitoneum of 800 cm³ caused by 2 centimetric avulsions of the splenic capsule (Fig. 1.D). No other lesions were observed intra-operatively. The bleeding was controlled by electrocoagulation and application of Floseal¹ and Traumastem.². She developed anemia at 7.9 g/dL on day 1 post-colonoscopy, requiring 2 units of red blood cells. The patient was monitored clinically and biologically and was discharged at day 7 post-colonoscopy.

Figs. 1.

A–B–C: Abdominal CT scan without intravenous contrast: presence of free fluid (red star) from the splenorenal recessus to the pelvis. D: Per-operative picture of the splenic capsular effraction (yellow arrow).

3. Clinical discussion

Colonoscopy is considered a low risk procedure. Several large studies have been made to analyze the rate of complications after colonoscopy, showing similar results. The global risk of complication after colonoscopy is estimated at 1.98 per 1000 examinations [2]. The two most common are bleeding and colic perforations, with a higher risk for bleeding than perforation: 2.6 per 1000 colonoscopies versus 0.5 per 1000 colonoscopies [7]. Overall mortality after colonoscopy is estimated at 2.9 per 100,000 examinations. The incidence rate of splenic injury after colonoscopy is estimated between 0.0005 % and 0.017 %. Splenic injury is a life-threatening complication, with 10 % of mortality [3]^, [4]^, [5]. It's rarity and therefore its non-suspicion can partly explain the high mortality rate. The speed of execution from the first symptoms to an appropriate treatment allows decreasing this mortality.

Mechanisms of splenic injury after colonoscopy are well suspected but have never been clearly proved [7]^, [8]^, [9]^, [10]^, [11]^, [12]. The most advanced explanation is an excessive traction on the splenocolic ligament when passing the left colonic angle. The tension is created with all the fixing structures of the spleen, reducing mobility of the colon: phrenicosplenic ligament, pancreaticosplenic ligament, gastrosplenic ligament with short vessels and splenorenal ligament (Fig. 2). Splenomegaly or adhesions due to previous abdominal surgery may increase this tension, but it has not been formally proved [8]. Another possible explanation is a direct trauma by the endoscope manipulation.

Fig. 2.

Spleen, colon, pancreas, diaphragm, splenocolic ligament, phrenosplenic ligament, pancreaticosplenic ligament, gastrosplenic ligament with short vessels. (Illustration based on the anatomy course of Professor B. Lengelé in Université catholique de Louvain, Faculty of Medicine.)

Risks factors for splenic injury after colonoscopy are female gender, older age, therapeutic colonoscopy and less experienced endoscopist [7]^, [8]^, [11]^, [12]. Other elements such as previous abdominal surgery, anesthesia assistance, technically challenging procedure, anticoagulation, usually perceived as risk factors have not yet demonstrated an increased risk. Similarly, parameters related to a patient's position during examination are difficult to assess due to the lack of information about its unfolding.

In 70 % of cases, patients develop symptoms during the first 24 h and in 80 % during the first 48 h after the colonoscopy. However, clinical manifestation can be sometimes delayed up to 8–10 days [9]. The most common presentation is a left-sided acute abdominal pain, associated with signs of hemodynamic instability such as vertigo and nausea. It may be associated with left shoulder pain (Kehr sign) but it's specificity after colonoscopy is around 50 %. Other signs such as chest pain have also been described, but are less frequent [8].

Abdominal CT scan with intravenous contrast injection is considered the gold standard exam in those situations, as it can detect extravasation of the intravenous contrast dye. Its sensitivity and specificity allow it to diagnose and to grade the splenic trauma [7]^, [8]^, [9]^, [10]^, [11]^, [12]. Ultrasonography can also be useful, as it is an easily available tool and useful to detect free intraperitoneal fluid with the FAST protocol (Focused Assessment with Sonography in Trauma) [10]. However, sensitivity of the ultrasonography is obviously operator dependent. Before the existence of the CT scan and ultrasound, the first splenic injuries were all diagnosed during laparotomy [8]. The advantage of these two diagnostic tools is that they also allow adopting an initial appropriate therapeutic attitude that is as minimally invasive as possible. In our case, the CT scan was performed without contrast. It revealed free intraperitoneal fluid without evidence of pneumoperitoneum. Therefore, the suggestion for splenic trauma was high but not proven. The relative hemodynamic stability of our patient allowed us to perform an emergency exploratory laparoscopy to get a clear diagnosis.

Depending on the grade of the splenic lesion, different treatments may be proposed. Classification of splenic trauma exists, such as the American Association for the Surgery of Trauma (AAST). However, this grading has not proven validity in the use with splenic injuries after colonoscopy [10]^, [11]. The hemodynamic instability of the patient is considered as the most determining factor for surgical intervention. The minor cases can be treated conservatively with intensive monitoring. More advanced cases can be treated by radio-embolization or by surgery [8]^, [9]^, [10]^, [11]^, [12]. In our case, we first did an emergency exploratory laparoscopy to have a final diagnosis before choosing our therapeutic attitude, in order to stay as conservative as possible. This decision allowed us to avoid laparotomy and to perform a splenectomy of the patient as the bleeding was controlled by laparoscopy.

4. Conclusion

Splenic injury after colonoscopy is a rare condition but with potentially lethal consequences. We suggest that endoscopists or associated caregivers should be aware of this life-threatening situation for every acute abdominal pain after colonoscopy. Abdominal CT scan with intravenous contrast is considered the gold standard exam in this situation. Its early suspicion, diagnosis and appropriate treatment may improve the prognosis of the patient. Patient's history, hemodynamic status and AAST classification for splenic injury must be considered in order to choose the best therapeutic attitude.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethical approval is exempt at authors institution for this case report.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guarantor

Nijs Yannick.

Research registration number

None.

CRediT authorship contribution statement

• RA: Conceived, designed and wrote the manuscript. Took care of the patient in the surgery unit and assisted the surgery.

• YN: Took care of the patient in the surgery unit and performed the surgery.

Declaration of competing interest

None.