When colonoscopy goes wrong: Surgical management of splenic rupture

Sergey Khaitov, MD

Resident

Department of Surgery

Russell Langan, MD

Tomas M. Heimann, MD

Professor

Department of Surgery

Mount Sinai School of

Medicine

New York, NY

Introduction: Splenic rupture is a rare, life-threatening complication of colonoscopy that is likely underreported in the literature. It can be treated conservatively or surgically, depending on the clinical and radiographic findings.

Results and discussion: The authors report a case of splenic rupture that presented in an elderly man 2 days after he underwent a colonoscopy. Although splenic rupture was not suspected, it was identified on computed tomography (CT ) scanning, and the patient was treated successfully with splenectomy. The authors review the literature and discuss the etiology, presentation, diagnosis, and treatment of splenic injuries.

Conclusion: CT scanning plays a key role in identifying splenic injuries. It should be used in patients who have recently undergone colonoscopy and present with abdominal pain or other symptoms that may indicate such injuries. This paper emphasizes the need for increased awareness of splenic rupture as a potential complication of colonoscopy and the high morbidity and mortality rates associated with it.

Routine fiberoptic colonoscopy has been regarded as a safe procedure, with complication rates of 0.029% to 0.72% and 0.2% to 2.67% for perforation and hemorrhage, respectively.¹ Less common complications include pneumothorax, septicemia, mesenteric tears, volvulus, and retroperitoneal abscess.^2-4 Splenic rupture is a rare complication and can be fatal if it is not diagnosed and treated early. Approximately 45 cases of splenic rupture secondary to colonoscopy have been reported in the English-language literature.^5,6 We report an additional case and review the relevant literature.

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.

Case report

An 83-year-old Hispanic man underwent an uneventful screening colonoscopy and polypectomy of two ascending colonic polyps. Two days later, he experienced shortness of breath and nausea and vomiting associated with epigastric abdominal pain that radiated to his lower back, which was aggravated whenever he was supine. He reported no recent history of trauma. His social history was significant for heavy smoking. The patient's medical history included chronic obstructive pulmonary disease, hypertension, coronary artery disease, benign prostatic hypertrophy, and a 4.7-cm abdominal aortic aneurysm.

On physical examination, the patient had stable vital signs. Mild diffuse abdominal tenderness without rebound or guarding was notable on palpation. Digital rectal examination was benign and negative for fecal occult blood. Significant laboratory findings included a hemoglobin count of 12.6 g/dL (normal, 14.0—17.5 g/dL) and a hematocrit of 39.1% (normal, 41%—50%).

Figure 1—CT scan showing a large splenic laceration, perisplenic hematoma, and massive hemoperitoneum.

Figure 2—Intraoperative photograph of the perisplenic hematoma.

Figure 3—Intraoperative photograph of the remaining spleen.

Figure 4—Gross pathology image of the ruptured spleen.

Contrast-enhanced computed tomography (CT) scanning revealed a large splenic laceration with perisplenic hematoma and massive hemoperitoneum (Figure 1). The abdominal aortic aneurysm was unchanged. After these radiographic procedures, the patient became hypotensive and reported increased abdominal pain. His hemoglobin dropped to 10.2 g/dL, and his hematocrit was 30.9%.

The patient was emergently transferred to the operating room. His spleen had ruptured and was actively bleeding, and more than 1 L of blood and clots were observed in the peritoneal cavity (Figure 2). A portion of the spleen was replaced by a hematoma with an eruption of the splenic capsule, but small parts of the spleen remained attached to the splenic pedicle (Figure 3). A splenectomy was performed. The patient had an uneventful recovery. He was vaccinated with polyvalent pneumococcal vaccine and discharged from the hospital on postoperative day 7 with a prescription for oral pain medication.

On macroscopic examination, a 50-g spleen, measuring 7.5 x 6.0 x 2.5 cm, was noted to have been stripped off its capsule, revealing a 2.5 x 2.0-cm defect in the hilar region. An area of soft parenchyma was noted centrally. No lacerations were identified, but a 10 x 7 x 5-cm hematoma was found. Sectioning of the gross specimen revealed red, spongy parenchyma (Figure 4).

Discussion

Splenic trauma related to fiberoptic colonoscopy is considered exceedingly rare. Two of the largest reviews evaluating complications related to colonoscopy included 7,959 patients by Smith and Nivatvongs and 5,000 patients by Macrae and Williams.^7,8 Neither of these studies reported any cases of splenic rupture. Because splenic rupture may be fatal, a high index of suspicion is critical in decreasing patient morbidity and mortality.

Etiology

Although a definitive etiology of splenic injury following fiberoptic colonoscopy has yet to be established, certain associations have been made. Presumed mechanisms include a decrease in the relative mobility between the spleen and colon secondary to splenocolic ligament adhesions from previous abdominal surgery, pancreatitis, or inflammatory bowel disease.^2,5,9 Splenic injury can result from colonoscopic techniques such as hooking the splenic flexure to straighten the descending colon, which causes an oppositional force on the splenocolic ligament and leads to an avulsion of the splenic capsule.^2,9 Operator maneuvers, including the slide-by technique, alpha maneuver, and straightening of the sigmoid loop, also place increased traction on the splenocolic ligament.³ External pressure on the left upper quadrant of the abdomen while a patient is supine can result in a splenic injury because the gravitational pull on the spleen and the traction from the colonoscope oppose one another.³ Although external abdominal pressure may sometimes be applied during colonoscopy to facilitate advancement of the colonoscope, it should be avoided. This technique can cause splenic injury, either through direct trauma to an enlarged spleen or by decreasing the mobility between the spleen and the colon.^2,3

Splenic injury is more common in cases where polypectomy or biopsy are performed because these procedures are associated with partial capsular avulsion.³ Other risk factors include underlying splenic diseases, especially splenomegaly, which predispose patients to direct trauma when the operator attempts to pass the splenic flexure with the colonoscope. Patients who have been anticoagulatedor have undergone multiple previous colonoscopies also have a higher risk of injury.^2,3

Presentation and diagnosis

Most patients who suffer splenic rupture following colonoscopy present with abdominal pain within 24 hours of the procedure, but some have presented as many as 10 days postcolonoscopy.^3,5 Pain is localized to the left upper quadrant of the abdomen and is accompanied by hypotension.⁵ Drops in hemoglobin and hematocrit levels are commonly observed.^5,9 Pain that radiates to the left shoulder, known as Kehr's sign, is nonspecific and experienced by 50% of all patients who undergo colonoscopy.⁵ Most patients present with intra-abdominal hemorrhage; thus, perforation and exsanguination should be ruled out.⁹

First, perforation should be ruled out, using an upright chest radiograph. Next, abdominal CT scanning with intravenous contrast should be undertaken.^5,9 This study can help differentiate complications such as splenic lacerations, active extravasation, and splenic hematoma from perisplenic clot formations or hemoperitoneum.^2,5 CT scanning can help clinicians determine whether conservative management is appropriate, such as in cases of closed subcapsular hematomas or when the splenic hilum is intact, or whether surgical treatment is required.^2,5,10

Treatment

Splenic rupture can be managed conservatively or surgically. Surgical intervention is required for patients with hemodynamic instability, underlying splenic disease, hemoperitoneum observed on CT scanning, and splenic injuries graded as 3 or higher according to the American Association for the Surgery of Trauma Splenic Injury Scale. Extremely young or elderly patients also benefit from early surgical intervention.¹⁰ A high failure rate of conservative management has been noted in patients who required transfusion of more than 1 unit of blood.¹⁰ Splenectomy is the procedure of choice for all hemodynamically unstable patients.

Stable patients who have closed, subcapsular splenic hematomas may be treated conservatively with broad-spectrum antibiotics, intravenous fluids, blood transfusion, and close hemodynamic monitoring.^2,5 Another safe and cost-effective treatment in hemodynamically stable patients with subcapsular hematomas is splenic artery embolization.¹¹ Agents include injectable embolic agents, sclerosing agents, and nonparticulate agents, such as stainless steel coils.⁹ Electrocoagulation through endovascular diathermy also has been described for embolization.⁹ When deciding on a treatment plan, the need for higher volumes of transfused blood should be balanced against the risk of postsplenectomy infection.¹¹

Splenectomy complications

Overwhelming postsplenectomy infection is a potentially devastating complication of asplenia that can occur any time after splenectomy. It is the most common cause of late mortality following these procedures. The exact incidence of such infections has been difficult to determine, because these cases are likely underreported.¹² The risk of infection has been shown to be higher in patients who undergo splenectomy for hematologic conditions and in pediatric patients who are younger than 4 years of age.

Overwhelming postsplenectomy infection is characterized by a brief prodromal phase, where the patient experiences malaise, myalgias, and a sore throat. This quickly escalates to an increasingly septic picture, where death can occur within hours after presentation. The mortality rate from fully developed overwhelming postsplenectomy infection remains high, ranging between 50% and 70%, despite improvements in antibiotics and supportive intensive care.¹³ This high mortality rate highlights the importance of preventive care. Clinicians must take great care in selecting which patients can be treated conservatively. All patients should be vaccinated with polyvalent pneumococcal vaccine, and immunocompromised patients should be selectively vaccinated against Haemophilus influenzae and Neisseria meningitidis. Prophylactic antibiotics should be administered for all pediatric patients.

Conclusion

Splenic rupture following colonoscopy is rare and can be overlooked easily. Delays in diagnosis are usually caused by a lack of knowledge regarding this complication. Splenic rupture was not included in the differential diagnosis of our patient and was discovered on CT scanning. The incidence of splenic injuries following colonoscopy may be significantly higher than is reported in the literature. Authors may be less inclined to report on these errors because of the level of morbidity associated with them.³ Splenic injury has also been reported following endoscopic retrograde cholangiopancreatography, which suggests that there is a higher incidence of endoscopic splenic injury than was once thought.³ With the increased use of colonoscopy as a preferred diagnostic modality, physicians should be cognizant of the complication of splenic rupture and must be able to recognize it on radiographic imaging, especially CT scanning.

References

1. Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancers in adults at average risk: a summary of the incidence for the US preventive services task force. Ann Int Med. 2002;137(2):132-141.
2. Ahmed A, Eller PM, Schiffman FJ. Splenic rupture: an unusual complication of colonoscopy. Am J Gastroenterol. 1997;92(7): 1201-1204.
3. Al Alawi I, Gourlay R. Rare complication of colonoscopy. ANZ J Surg. 2004;74(7):605-606.
4. Espinal EA, Hoak T, Porter JA, et al. Splenic rupture from colonoscopy. A report of two cases and review of the literature. Surg Endosc. 1997;11(1):71-73.
5. Zenooz NA, Win T. Splenic rupture after diagnostic colonoscopy: a case report. Emerg Radiol. 2006;12(6):272-273.
6. Luebke T, Baldus SE, Holscher AH, et al. Splenic rupture: an unusual complication of colonoscopy: case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2006;16(5): 351-354.
7. Smith LE, Nivatvongs S. Complications in colonoscopy. Dis Col Rectum. 1975;18:214-220.
8. Macrae FA, Williams CB. Toward safer colonoscopy: a report on the complications of 5000 diagnostic and therapeutic colonoscopies. Gut. 1983;24:376-383.
9. Olshaker JS, Deckleman C. Delayed presentation of splenic rupture after colonoscopy. J Emerg Med. 1999;17(3):455-457.
10. Stein DF, Myaing M, Guillaume C. Splenic rupture after colonoscopy treated by splenic artery embolization. Gastrointest Endosc. 2002;55(7):946-948.
11. Janes SE, Cowan IA, Dijkstra B. A life-threatening complication after colonoscopy. BMJ. 2005;330(7496):889-890.
12. Horowitz J, Smith JL, Weber TK, et al. Postoperative complications after splenectomy for hematologic malignancies. Ann Surg. 1996;223(3):290-296.
13. Holdsworth RJ, Irving AD, Cushieri A. Postsplenectomy sepsis and mortality rate: Actual versus perceived risk. Br J Surg. 1991;78:1031-1038.

Self-assessment questions

1. What is the optimal timing for vaccinating patients undergoing splenectomy?
   1. One month before elective splenectomy
   2. Two weeks before elective splenectomy
   3. Four weeks following emergency splenectomy
   4. Two months following emergency splenectomy
   5. First postoperative clinic visit following emergency splenectomy
2. All the following are associated with failure of conservative management of splenic laceration, except:
   1. Patient is of advanced age
   2. Massive hemoperitoneum
   3. Need for transfusion of more than one unit of blood
   4. Presence of contrast "blush" on CT scan
   5. Patient is a child
3. Which of the following patients is least likely to develop overwhelming postsplenectomy infection?
   1. A 30-year-old man with stage IIB Hodgkin's disease
   2. A 40-year-old man with grade V injury
   3. A 3-year-old child with hereditary spherocytosis
   4. A 12-year-old child with hereditary spherocytosis
   5. A 3-year-old child with grade V injury
4. Which of the following factors was associated with splenic trauma from colonoscopy in the literature?
   1. Polypectomy during colonoscopy
   2. Splenomegaly
   3. Applying external pressure to the abdomen to facilitate advancing the colonoscope past the splenic flexure
   4. History of multiple laparotomies
   5. All of the above

Read the Answers

Self-assessment answers

1. b—In elective settings, it is recommended patients be vaccinated with polyvalent pneumococcal vaccine 2 weeks before splenectomy. Patients undergoing emergency splenectomy should be vaccinated prior to their discharge from the hospital, given the high rate of noncompliance.

2. e—Overall, the success rate for nonoperative management of splenic lacerations is greater for children than adults.

3. b—The risk of overwhelming postsplenectomy infection is higher in patients who receive splenectomy to manage a hematologic disease. The risk of developing overwhelming infection after trauma-related splenectomy is higher in children than adults, which is why children should be given postsplenectomy prophylaxis with antibiotics in addition to vaccination.

4. e—Numerous factors have been associated with splenic injury from colonoscopy. In addition to the factors listed in the question, inflammatory conditions such as pancreatitis and colitis, "hooking" of the splenic flexure, and reduction of the colonoscope loop are said to contribute to placing excessive traction on the splenocolic ligament.