2/11/2017 SplenicInjuryafterElectiveColonoscopy

JSLS.2009OctDec13(4):616619. PMCID:PMC3030803

SplenicInjuryafterElectiveColonoscopy
MohammadSarhan,MD, AlexiusRamcharan,MD,andSarmaPonnapalli,MD
MohammadSarhan,DepartmentofSurgery,HarlemHospitalCenter,NewYork,NewYork,USA.
ContributorInformation.
Correspondingauthor.
Addresscorrespondenceto:Addresscorrespondenceto:MohammadSarhan,MD,HarlemHospitalCenter/DepartmentofSurgery,506LenoxAvenue,
NewYork,NY,10037,USA.

Copyright2009byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.

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Abstract Goto:

Splenicinjuryisararebutseriouscomplicationofcolonoscopy.Sincethemid1970s,68splenicinjuriesduring
colonoscopyincludingour2caseshavebeendescribed.Withtheincreasinguseofcolonoscopy,endoscopists,
surgeons,andradiologistsaremorelikelytoencounterthisunusualcomplication.Anycauseofincreased
splenocolicadhesions,splenomegaly,orunderlyingsplenicdiseasemightbeapredisposingfactorforsplenicinjury
duringcolonoscopy.However,itcanoccurinpatientswithoutsignificantadhesionsorunderlyingsplenic
pathology.Thediagnosisisoftendescribedintheliteratureasdelayed,becausemanyphysiciansarenotawareof
thiscomplicationofcolonoscopy.Althoughcomputerizedtomographyishighlysensitive,knowledgeofthis
complicationisthebesttooltoaidinearlydiagnosis.Patientswithabdominalpain,hypotension,andadropin
hematocritwithoutrectalbleedingaftercolonoscopyshouldbesuspectedofhavingsplenicinjury.Early
recognitionandinterdisciplinarymanagementarerequiredtoassuresuccessfulmanagementofthispotentiallylife
threateninginjury.Patientswithhemodynamicinstabilitymostoftenundergosurgery.Wepresent2casesofsplenic
injurysecondarytocolonoscopythatrequiredsplenectomy.

Keywords:Splenicinjury,Colonoscopy,Splenectomy

INTRODUCTION Goto:

Colonoscopyhasbecomearoutineinvestigationinthediagnosisandtreatmentofmanycolonicdiseases.
Complicationsarefewandconsistmainlyofhemorrhage(1%to2%)andcolonicperforation(0.1%to0.2%).
Otherrarecomplicationsincludebacteremia,vasovagalproblems,ileus,EKGabnormalities,mesenterictears,
pneumothorax,pneumoperitoneum,pneumoscrotum,andcolonicvolvulus.1,2,3

Splenicinjuryaftercolonoscopyisrare,serious,andmaybecomealethalcomplicationoftheprocedure.Themost
likelymechanismistensiononthesplenocolicligamentoronpreexistingadhesionsduetomanipulationsofthe
colon,orasaresultofadirectinjurytothespleenduringpassagethroughthesplenicflexure.Intraperitoneal
adhesionsoranyunderlyingsplenicpathologymayincreasetherisk.

Withtheincreasinguseofcolonoscopy,physiciansshouldbeawareoftherarelifethreateningcomplicationofthis
procedure.Wepresent2casesofsplenicinjuryaftercolonoscopyinwhichsplenectomywasmandatory.We

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reviewedtheworldliteraturebyusingPubmedandMedlinetoidentifythemechanism,riskfactors,presenting
signsandsymptoms,preventivemeasures,anddiagnosticandmanagementoptions.

CASEREPORT1 Goto:

A56yearoldwomanwithapastmedicalhistoryofasthma,cholecystectomy,andhysterectomy,underwent
routinescreeningcolonoscopy.Sevenpolypswereremovedintheascending,transverse,andsigmoidcolon
withoutdifficulties.Eighthourslater,thepatientdevelopedseverediffuseabdominalpainthatprogressively
worsened.Shereturnedtotheemergencydepartment,whereherbloodpressurewas70/40mmHg,andherheart
ratewas120/minute.Onphysicalexamination,shehaddiffuseabdominaltenderness,rebound,andguarding.Her
hematocritdroppedto30mg/dLfromaprecolonoscopyvalueof41mg/dL.ShewasresuscitatedwithIV
crystalloids.CTscanoftheabdomenandpelvisrevealedsplenicinjurywithalargeamountofbloodintheleft
upperquadrant,perihepaticregion,andpelvicareas(Figure1).

Figure1.
CTabdomenwithintravenousandoralcontrast.Freeperihepaticand
perisplenicfluidscanbeseen,hounsfielddensityconsistentwithblood.
Arrowpointtothemediallydisplacedspleenbythesurroundinghematoma.

Thepatientunderwentexploratorylaparotomythatrevealed2000mLofbloodandclotsintheperitonealcavity
andnonperforatedcolon.Multipleadhesionswerenotedbetweentheomentumandtheliver,colon,spleen,and
stomach.Lysisofadhesionswasdone,thesplenocolicligamentwasdivided,andthesplenicflexurewas
mobilized.Activebleedingfromthesplenichilumwasseen,andasplenectomywasperformed.Surgicalpathology
examinationshowedarupturedspleenwithnounderlyingsplenicpathology.Thepostoperativecoursewas
smooth.Thepatientremainedstableoverthecourseofherhospitalization.Shetoleratedanoraldietonthesecond
postoperativedayandwasdischargedhomeafterreceivingpostsplenectomyvaccinationsonthefourth
postoperativedaywithanuneventfulpostoperativerecovery.

CASEREPORT2 Goto:

A55yearoldwomanwithnosignificantpastmedicalhistoryunderwentaroutinescreeningcolonoscopy.Two
smallflatpolypswereremovedfromthehepaticflexure,andonesessilepolypwasremovedfromthececum.
Twelvehourslater,shepresentedtotheemergencydepartmentwithsevereabdominalpain,nausea,andvomiting.
Herheartratewas73/minuteandbloodpressurewas100/50mmHg.Herabdomenwassoft,distended,andtender
inbothleftlowerandleftupperquadrants.Herhematocritonpresentationwas39mg/dL,whileitwas44mg/dL
beforecolonoscopy.CTscanoftheabdomenandpelvisshowedfreeintraperitonealbloodwithhematomaaround
thespleendisplacingthespleenmedially(Figure2).

Figure2.
CTabdomenwithintravenousandoralcontrast.Arrowpointtothemedially
andanteriorlydisplacedinjuredspleenwiththesurroundinghematoma.

Exploratorylaparotomyrevealed1500mLoffreshbloodintheperitonealcavityand500mLofclotsaroundthe
spleen.Thesplenocolicandrenocolicligamentsweredivided,andthesplenicflexuremobilized.Bleedingwas
activearoundthesplenichilum.Splenectomywasperformed.Thecolonandtheremainingintraperitonealorgans
appearednormal,andnoadhesionswereseen.Surgicalpathologyshowedarupturedspleenwithnounderlying
splenicpathology.Thepatienttoleratedtheprocedurewell.Shewasstartedonanoraldietonthefirstpostoperative
day.Shereceivedpostsplenectomyvaccinationsandwasdischargedhomeonthethirddayaftersurgerywithan
uneventful,stablepostoperativecourse.

DISCUSSION Goto:

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Areviewoftheliteratureindicatesthatthefirstcaseofsplenicinjuryassociatedwithcolonoscopywasreportedin
1974,5andfewerthan70caseshavebeenreportedintheworldliteraturesincethen.9Themostlikelymechanism
forthiscomplicationistensiononthesplenocolicligament,oronpreexistingadhesions,oronboth,dueto
manipulationsofthesigmoid,descendingcolon,ortransversecolon,orduetoamoredirecteffect,occurring
duringthepassageoftheendoscopethroughthesplenicflexureresultinginparenchymaltearsoravulsionofthe
spleen.1Splenicrupturecanoccurinanormalspleenafteratechnicallydemandingcolonoscopy.Patientswitha
historyofpreviousabdominalsurgeryortraumaareatincreasedriskforsplenicinjuryduetothepresenceof
splenocolicadhesions.Hematological,infectious,andinfiltrativediseasesthatleadtosplenomegaly,inflammatory
boweldisease,andpancreatitisincreasetheriskforsplenicruptureaftercolonoscopy.2Inareviewof8patients
withsplenicinjury,Petersenetal9foundthatloopscausingdifficultiesoccurredduringthecolonoscopyin4
patients.However,manysplenicinjurieshaveoccurredinreportedlyeasycolonoscopiesinpatientswithout
significantadhesions.6Othercontributingfactorstosplenicinjuryincludecertaintechniquesusedtonavigatethe
splenicflexure,suchastheblindadvancementoftheendoscopepastthesplenicflexureandhookingthesplenic
flexuretostraightentheleftcolon.6Splenicinjuryhasalsobeenreportedinassociationwithcolonicperforation
aftercolonoscopyandfollowingendoscopicretrogradecholangiopancreatographyin2casereports.4,7

Themostcommonsignsandsymptomsareabdominalpainwithoutradiographicevidenceofperforation,left
shoulderpain,peritonealirritation,andorthostaticchanges.Duetoalowindexofsuspicion,manyofthe
previouslyreportedcaseswerediagnosedrelativelylateupto10daysaftertheprocedure.8Viamonteetal4ina
reviewof14patientswithsplenicinjuryaftercolonoscopyobservedabdominalpainin64%ofthepatientssoon
aftertheprocedure,andthathemodynamicinstabilitywasnearlyuniversallyseen.Inareviewof8cases,Petersen
etal9foundthatallpatientsweresymptomfreeaftercolonoscopy,for4hoursto7days.Thediagnosiscanbe
problematic,partlybecauseofthecharacteristicsymptomfreeintervalandpartlybecausereferringphysiciansor
evenendoscopistsmightnotbeawareofthisunusualcomplicationoftheprocedure.

CTscanishighlyaccuratefordetectingsplenicinjuryandtheextentofhemoperitoneum.Thisexaminationis
consideredthediagnosticmodalityofchoiceinastablepatient.6Espinaletal6inareviewof17casesfound8
patientswerediagnosedbyCTscan,6bylaparotomy,and1eachbyangiography,ultrasound,andautopsy.
Althoughsplenectomyisrequiredinthemajorityofcases,observationorsplenorrhaphymaybeoptionsinselect
cases.6Thenonoperativeapproachisusuallytakeninpatientswithnointraperitonealblood,aclosedsubcapsular
hematoma,andastablehemodynamicstatus.3

Preventivemeasuresincludegoodcolonoscopytechniquetoavoidloopformationandtoavoidtheuseofexcessive
force.9Theleftlateralpositionofthepatientmayreducetheriskofsplenicinjuryaftercolonoscopycomparedwith
thesupineposition.Itisreasonedthatthesupinepositionexertsopposingforcesonthespleenfromgravityand
traction.Thisleadstoanincreaseinthespleniccapsuletear,especiallyifotherpredisposingfactorsarepresent,
suchaspreviousabdominalsurgery.Ithasbeensuggestedthattheeffectoftheseforcesmightdecreaseintheleft
lateralposition.10

Inbothofourcases,thecolonoscopywasuneventfulpresentationwaswithin12hoursaftertheprocedure,andthe
CTscandemonstratedsplenicinjury.Conservativemanagementwasnotanoptionineithercaseduetothe
presenceofactivebleedingandalargeamountoffreeintraperitonealblood.Ofnoteisthatneitherofthe2patients
hadprimarysplenicpathologicaldiseasethatmightaccountforrupture.Oneofthepatientshaddenseadhesions
fromaprevioussurgery.

CONCLUSION Goto:

Theincidenceofsplenicruptureaftercolonoscopymaybehigherthansuggestedintheliterature,asmanyauthors
arenoteagertopublicizetheirmorbidity.Theendoscopistshouldsuspectsplenicinjuryaftercolonoscopyina
patientwhodevelopsabdominalpainandtendernesswithoutanyevidenceofbowelperforationorrectalbleeding
withorwithouthemodynamicinstability.Excessiveforceandloopformationshouldbeavoidedduring

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2/11/2017 SplenicInjuryafterElectiveColonoscopy

colonoscopy.Althoughpatientswithintraperitonealadhesionsandthosewithunderlyingsplenicpathologyhavea
greaterchanceofexperiencingthiscomplication,splenicinjurycanoccurinanormalspleenandwithout
intraperitonealadhesions.Exploratorylaparotomyshouldbeconsideredforunstablepatientsandthosewithactive
bleedingintheperitonealcavity.Inour2cases,thespleencouldnotbepreserved,andsplenectomywasmandatory
becausetheinjurycouldnotbemanagedusingconservativetechniques.Inastablepatient,abdominalCTscanis
advisabletohelpinthediagnosisandtoselectthosepatientswhomaybemanagedconservatively.

ContributorInformation Goto:

MohammadSarhan,DepartmentofSurgery,HarlemHospitalCenter,NewYork,NewYork,USA.

AlexiusRamcharan,DepartmentofSurgery,HarlemHospitalCenter,NewYork,NewYork,USA.Columbia
University,NewYork,NewYork,USA.

SarmaPonnapalli,WoodhullMedicalCenter,NewYork,NewYork,USA.

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