AJR 2005; 185:708-710
© American Roentgen Ray Society
Splenic Injury After Colonoscopy: Conservative Management Using CT
Joan C. Prowda1,
Susan Garrett Trevisan2 and
Anna S. Lev-Toaff3
1 Department of Radiology, Columbia University Medical Center, 177 Fort
Washington Ave., MHB 3-244, New York, NY 10032.
2 Department of Radiology, Doylestown Hospital, Doylestown, PA 18901.
3 Department of Radiology, Thomas Jefferson University Hospital, Philadelphia,
PA 19107.
Received July 29, 2004;
accepted after revision September 27, 2004.
Address correspondence to J. C. Prowda
(jcp2005{at}columbia.edu).
Introduction
As the use of colonoscopy has increased greatly in recent years,
awareness of its complications has become more important. Hemorrhage is the
most common complication, with an incidence of 1-2%
[1]. Perforation is the next
most common complication, with an incidence of 0.1-0.2%
[1]. Unusual complications of
colonoscopy include pneumothorax, septicemia, mesenteric tears, and colonic
volvulus. Splenic trauma is a rare complication of colonoscopy and was first
reported by Wherry and Zehner in 1974
[2]. Two early studies that
included nearly 13,000 patients reported no cases of splenic rupture
[3,
4]. Since then, at least 26
cases of splenic rupture after colonoscopy have been reported in the
English-language surgical and medical literature
[5,
6]. To our knowledge, there is
only one such report in the English-language radiology literature
[7]. Given the increasing use
of colonoscopy, it is important that radiologists are aware of this rare but
potentially fatal complication of colonoscopy. We present two cases of splenic
injury secondary to colonoscopy that were diagnosed by sonography and CT and
managed conservatively by clinical observation and follow-up CT scans.
Case Reports
Case 1
An 85-year-old woman with a remote history of peptic ulcer disease and no
history of abdominal surgery presented with rectal bleeding, a hemoglobin of
11.9 g/dL, and a hematocrit of 35.8%. She used nonsteroidal anti-inflammatory
medications occasionally. Colonoscopy was performed with mild difficulty
intubating the left colon and splenic flexure. The mucosa was noted to be
hyperemic; biopsies revealed proctitis. After the procedure, the patient
developed abdominal pain that was intermittent, sharp, and radiated to the
left shoulder (Kehr's sign). This pain worsened with movement, breathing, and
coughing. An obstruction series performed that evening in the emergency
department revealed no free air and the patient was discharged. At the time,
the patient's hemoglobin was 9.6 g/dL with a hematocrit of 29.6%.
Five days after the colonoscopy, the patient complained of persistent
abdominal pain. Abdominal sonography performed as an outpatient revealed a 10
x 5 x 10 cm complex collection adjacent to the spleen and a
moderate amount of free fluid in the pelvis. The patient was admitted to the
hospital and a CT scan with oral and IV contrast media was performed. This
revealed a low attenuation collection inseparable from the posteromedial
aspect of the spleen (Fig. 1A) and a 4.5-cm fluid collection inferior in relation to the spleen
(Fig. 1B), consistent with a
subcapsular and perisplenic hematoma. A moderate amount of high density fluid
was present in the pelvis, indicating hemoperitoneum
(Fig. 1C). The patient's
hemoglobin was 8.8 g/dL and hematocrit was 27.3%. Since the patient was
hemodynamically stable, she was treated conservatively. The pain decreased in
severity and her hemoglobin and hematocrit stabilized at 8.9 g/dL and 26.4%;
she was discharged the following day. Follow-up CT
weeks later revealed a
decrease in the size of the splenic hematoma
(Fig. 1D) and resolution of
fluid collection inferior to the spleen
(Fig. 1E).
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Fig. 1A —85-year-old woman with splenic hematoma and hemoperitoneum
presenting 5 days after colonoscopy, treated conservatively with clinical and
CT follow-up. Initial CT through inferior part of spleen shows hypodense
hematoma in posteromedial aspect.
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Fig. 1B —85-year-old woman with splenic hematoma and hemoperitoneum
presenting 5 days after colonoscopy, treated conservatively with clinical and
CT follow-up. Initial CT several centimeters caudal to A shows 4.5-cm
fluid collection inferior in relation to spleen.
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Fig. 1C —85-year-old woman with splenic hematoma and hemoperitoneum
presenting 5 days after colonoscopy, treated conservatively with clinical and
CT follow-up. Initial CT through lower pelvis shows moderate amount of high
density fluid in cul-de-sac.
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Fig. 1D —85-year-old woman with splenic hematoma and hemoperitoneum
presenting 5 days after colonoscopy, treated conservatively with clinical and
CT follow-up. Follow-up CT
weeks later shows interval decrease in size of splenic hematoma.
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Fig. 1E —85-year-old woman with splenic hematoma and hemoperitoneum
presenting 5 days after colonoscopy, treated conservatively with clinical and
CT follow-up. Follow-up CT shows resolution of fluid collection inferior in
relation to spleen.
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Case 2
A 48-year-old woman with a surgical history of right salpingectomy
presented to the emergency department with pain in the left upper quadrant of
the abdomen that radiated to the left shoulder. The pain began a few hours
after colonoscopy, which was performed uneventfully, to evaluate chronic
diarrhea. The patient had presented to an outside hospital where an
obstruction series showed large-bowel distention but no free air. The patient
was discharged on metoclopramide and dicyclomine. The pain did not subside
completely and the patient reported a low-grade fever. She presented again 7
days after the colonoscopy. A CT scan revealed a subcapsular and perisplenic
hematoma (Fig. 2) and a small
amount of high density fluid (blood) in the pelvis. The patient's hemoglobin
was 12 g/dL with a hematocrit of 33.5%. She was admitted for observation. Two
days later, a CT scan revealed no change in the splenic hematoma. The
patient's blood count remained stable and she was discharged 3 days later. A
CT scan performed 2 weeks after discharge showed a decrease in the size of the
splenic hematoma and resolution of the pelvic fluid.
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Fig. 2 —48-year-old woman presenting 7 days after colonoscopy with
large subcapsular/perisplenic hematoma and small hemoperitoneum was treated
conservatively with clinical and CT follow-up. Initial CT through spleen shows
subcapsular hematoma of heterogeneous attenuation with mass effect on
spleen.
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Discussion
There are three presumed mechanisms of splenic injury secondary to
colonoscopy: First, splenic injury may be secondary to excessive traction on
the splenocolic ligament, leading to tears in the splenic capsule or capsular
avulsion. Second, preexisting adhesions between the spleen and colon can lead
to excessive traction on the spleen during even easy intubation, because of
decreased mobility between the spleen and colon. Situations predisposing to
adhesions and decreased mobility include prior trauma or surgery, inflammatory
bowel disease, and pancreatitis. Direct trauma to the spleen during difficult
intubation is the final presumed mechanism
[5,
6]. Patients with splenomegaly
or other diseases involving the spleen are at higher risk for splenic injury
during colonoscopy
[4-7].
Neither of our patients had splenic abnormalities before the procedure or a
history of gastrointestinal inflammatory disease or abdominal surgery.
Most patients with splenic rupture report symptoms within the first 24 hr,
but symptoms can be delayed for up to 3 days. The most common signs and
symptoms are abdominal pain without radiographic evidence of perforation, left
shoulder pain (Kehr's sign), peritoneal irritation, and orthostatic
changes.
An abdominal radiograph may be obtained to exclude free air, after which a
CT scan of the abdomen and pelvis is the preferred examination to evaluate for
other complications. Previous cases of splenic trauma secondary to colonoscopy
have been diagnosed with CT scan, laparotomy, angiography, sonography, and
autopsy [5]. Given the known
accuracy of CT for splenic and other visceral injuries, the prompt use of CT
in patients complaining of pain shortly after colonoscopy or with persistent
pain days after colonoscopy is advisable. The decision to operate is aided by
CT findings but ultimately depends on the clinical judgment of the referring
physician. A nonoperative approach is usually taken with patients with no
intraperitoneal blood, a closed subcapsular hematoma, and a stable hemodynamic
status [1,
5]. In the cases presented, the
patients had a small to moderate hemoperitoneum but showed no signs of active
bleeding or vascular injury on the initial CT. On clinical examination, both
patients were hemodynamically stable. Follow-up CT showed improvement in each
case and, therefore, pathologic diagnosis was not obtained. CT promoted
conservative management by defining the injury and excluding significant
vascular or bowel injury; follow-up CT also provided reassurance of interval
resolution.
With the increasing use of colonoscopy, radiologists are more likely to
encounter the unusual complications of this procedure. Radiologists should be
aware of this rare but potentially fatal complication of colonoscopy when
patients are referred for abdominal pain. Since this complication may present
shortly after colonoscopy or on a delayed basis, it is important to elicit the
history of colonoscopy. If no clinical or plain radiographic evidence of
colonic perforation or external bleeding is seen, CT of the abdomen and pelvis
should be performed to evaluate for splenic injury and other rare injuries,
including hepatic and mesenteric injuries. The pelvis should be included to
assess the amount of hemoperitoneum. The use of IV contrast media is important
to assess the extent of splenic injury and to evaluate for possible active
bleeding. These factors, along with the patient's clinical status, help to
triage patients to observation and follow-up or to more aggressive treatments
such as embolization and surgery.
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Introduction
Case Reports
