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SAGE Open Med Case RepSAGE Open Med Case RepSCOspscoSAGE Open Medical Case Reports2050-313XSAGE Publications Sage UK: London, England 10.1177/2050313X1879106910.1177_2050313X18791069Case ReportA delayed presentation of splenic laceration and hemoperitoneum
following an elective colonoscopy: A rare complication with uncertain risk
factors https://orcid.org/0000-0002-9486-6520Zhang Allison N Sherigar Jagannath M Guss Debra Mohanty Smruti R Division of Gastroenterology and Hepatobiliary
Diseases, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY,
USAAllison N Zhang, Division of
Gastroenterology and Hepatobiliary Diseases, NewYork-Presbyterian Brooklyn
Methodist Hospital, 506 sixth Street, Brooklyn, NY 11215, USA. Email:
alzhang16@gmail.com30 7 2018 2018 6 2050313X1879106918 3 2018 5 7 2018 © The Author(s) 20182018SAGE PublicationsThis article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which
permits non-commercial use, reproduction and distribution of the work
without further permission provided the original work is attributed as
specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).Splenic laceration is a rare yet often underreported complication of colonoscopy
that is infrequently discussed with the patient during the consent process. Most
cases present within 48 h after the inciting colonoscopy; a delayed presentation
is rare. We present a case of splenic laceration with hemoperitoneum that
manifested 5 days after the initial colonoscopy. The patient was treated
conservatively. Traditionally perceived risk factors such as intra-abdominal
adhesions, splenomegaly, anticoagulation use, biopsy, polypectomy, a technically
challenging procedure, and anesthesia assistance have not been clearly shown to
increase the incidence of splenic injury following a colonoscopy. Since the risk
factors of splenic injury remain unclear, the clinical presentation is
nonspecific, and the consequences can be serious, the endoscopist should make an
effort to inform the patient of this rare complication before the procedure.

Splenic injurysplenic lacerationhemoperitoneumcolonoscopy complicationscover-dateJanuary-December 2018
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Introduction
Colonoscopy is a widely adopted tool for colorectal cancer screening.1,2 Although it is generally a safe
procedure, it does carry a small risk of complications. Two of the most frequently
reported complications are bleeding and perforation, with an incidence of 0.17-0.53%
and 0.046-0.25%, respectively.3,4 Less common complications
include pneumomediastinum, pneumothorax, volvulus, hernia incarceration,
retroperitoneal abscess, retroperitoneal emphysema, appendicitis, septicemia, and
splenic laceration, not all of which are routinely disclosed to the patient during
the consent process.5,6
Splenic injury (SI) is an infrequent complication of colonoscopy that is often
underrecognized and underreported, yet can lead to significant morbidity and
mortality.1,5
It was first documented in 1974 and since then, only over 100 cases have been
indexed in the world literature.4,7 Due to its rarity, our knowledge
about its occurrence has been limited to case reports and case series. Most cases of
SI manifest within 48 h after the inciting colonoscopy; a delayed presentation is
rare.6,8 We report a
delayed presentation of splenic laceration post-colonoscopy that was managed
conservatively. This case also highlights the fact that this complication may be far
more common than reported as many patients may not develop symptoms significant
enough to warrant medical attention.

Case presentation
A 63-year-old female with a medical history of type II diabetes mellitus,
hypertension, seizure disorder, gastroesophageal reflux disease, gout, and vitamin D
deficiency presented to the emergency department (ED) with a 2-day history of
worsening abdominal pain. The patient described the pain as crampy and worse on the
left side. She had undergone an outpatient colonoscopy 5 days prior to evaluate a
recent history of weight loss. The colonoscopy was not reported to be difficult, and
only diverticulosis was found. There were no other intraoperative events. The
patient denied trauma following the procedure. She reported dizziness but not
nausea, vomiting, change in bowel habits, hematochezia, melena, fever, or chills. A
physical examination revealed diffuse abdominal tenderness that was worse in the
left upper and lower quadrants. There was no guarding. Her vital signs were stable:
the blood pressure was 163/67, heart rate was 93, respiration was 15, and
temperature was 36.7°C.

Laboratory studies revealed a hemoglobin (Hgb) of 9.1 g/dL, down from a baseline of
11.5 g/dL. Her white cell count was 6.8 K/μL and creatinine was 0.58 mg/L. Other
studies including the liver enzymes, bilirubin, lipase, albumin, coagulation
profile, and urine analysis were unremarkable. An upright chest X-ray showed no free
air under the diaphragm. A contrast-enhanced computed tomography (CT) of the abdomen
and pelvis was performed which demonstrated a 1.2 cm posterior inferior splenic
laceration with a 7.6 × 3.4 cm subcapsular splenic hematoma and a moderate
hemoperitoneum (Figure 1).
Incidentally, radiographic changes of chronic pancreatitis were also identified,
including pancreatic atrophy, diffuse pancreatic calcifications, and pancreatic duct
dilatation. This was likely related to the patient’s history of alcohol abuse.

Figure 1. (a) Subcapsular splenic hematoma. The spleen (arrowhead) is displaced by
high-density fluid (Hounsfield unit of 69, arrow) consistent with a
loculated hematoma underneath the splenic capsule. (b) Splenic laceration.
There is a linear defect in the spleen (arrow) measuring 1.2 cm in depth
representing a splenic laceration. (c) Hemoperitoneum. There is free fluid
(arrow) in the peritoneal cavity that displays a Hounsfield unit of 65
consistent with blood, in contrast to the fluid content of the bladder
(arrowhead) which has a Hounsfield unit of 15.

The differential diagnoses prior to the diagnostic CT included colonic perforation,
diverticulitis, and acute pancreatitis. Since the patient had stable hemodynamics, a
conservative approach was employed. She received fluid resuscitation and was
admitted to the surgical step-down unit for observation. Her symptoms improved
significantly over the next 2 days and her Hgb and vital signs remained largely
unchanged. She was discharged home on day 3 of the hospitalization.

The patient was evaluated 2 weeks after discharge in the clinic setting. Her
abdominal pain had completely resolved and her Hgb was restored to 12.4 g/dL. An
upper abdominal ultrasound was performed 1 month post-discharge and revealed
resolution of the hemoperitoneum and a reduction in the size of the splenic hematoma
(4.3 × 3.2 cm).

Discussion
SI is a rare complication of colonoscopy.1,4 It is thought to be
underrecognized and underreported, and thus, its exact incidence is not
known.1,5 The most
extensive study to date of over 3 million patients suggested an incidence of
0.0045%, which was higher than previously estimated.1,4,7,9 It has a mortality of 5% and can
lead to significant morbidity given that the majority of patients require a
splenectomy.1,2
More than 80% of the patients present within 48 h after the inciting colonoscopy;
however, symptom onset can be delayed up to 8 days.6,8 The most frequent symptoms
include abdominal pain, referred pain to the left shoulder (Kehr’s sign), and
hypotension.2,5
These can be nonspecific however, so a high index of clinical suspicion is essential
for the diagnosis. In fact, post-procedural abdominal pain is often attributed to
air insufflation, and a small splenic laceration presenting in this manner could be
missed.

The gold standard for diagnosis is a contrast-enhanced CT, which not only evaluates
the extent of the SI but also identifies active extravasation and other
intra-abdominal pathologies.10–12 It
additionally has a sensitivity and specificity higher than non-contrast CT and
ultrasound, exceeding 95% in several studies.10,11 If the patient is unable to
tolerate CT due to hemodynamic compromise, a bedside ultrasound can be
considered.1,2,10–12 The American Association for
the Surgery of Trauma divides the severity of SI into five levels.1,12,13 Injuries grade III and above
are likely to fail non-operative management. However, this scheme applies to
traumatic SIs only and has no proven validity or predictability for
colonoscopy-related SIs.5,13 In this scenario, hemodynamic instability has been determined
to be the best indicator for surgical intervention.1,13 Additional indications for
surgery may include a hemoperitoneum which predicts progression to shock, and
persistent symptoms despite initial conservative management.13,14 Studies have
shown that more than 75% of known SI cases required splenectomy as the definitive treatment.2 Splenic artery embolization can also be considered in patients with active
bleeding but stable hemodynamics.13

The mechanisms of SI during a colonoscopy are thought to be due to excessive traction
on the splenocolic ligament by the scope as well as direct trauma to the spleen
during the scope insertion, leading to splenic capsule avulsion.1 It has been proposed that adhesions from a prior surgery and chronic
inflammation due to pancreatitis, diverticulosis, or inflammatory bowel disease can
decrease the mobility between the spleen and the colon, thus predisposing a patient
to SI.5,6 However, such an
association has not been clearly established in the literature.1,2,5,6 In fact, most studies have shown
that the larger proportion of patients who experienced SI post-colonoscopy did not
have adhesions during laparotomy.2,5,7 Our patient was incidentally
found to have chronic pancreatitis on CT, but it was unclear whether this was a risk
factor for her SI. Similarly, there have been no clear correlations found between
the incidence of SI and older age, anticoagulation use, splenomegaly, biopsy,
polypectomy, or a technically difficult colonoscopy.1,2,5–7 The only association noted was
with the female gender (78%). It is, therefore, challenging to predict which
patients are at risk of developing SI during a colonoscopy. Anesthesia assistance
during colonoscopy has also been proposed to increase the risk of SI due to an
impaired sensation and expression of pain by the patient, although two major studies
have proved this to be false.4,15 Anesthesia was not found to increase the risk of perforation,
bleeding, or SI, although it did increase the risk of aspiration pneumonia during
colonoscopy. Procedural factors such as the slide-by advancement, hooking at the
splenic flexure to straighten the sigmoid loop, creating an alpha loop, applying
external pressure to the left hypogastrium, and supine positioning may all
exacerbate the tension on the splenocolic ligament and predispose the patient to
SI.1,5 However, since
most colonoscopy reports do not contain information on the maneuvers performed
intraoperatively, it would be difficult to establish these maneuvers as the cause of
SI.

Given that SI due to colonoscopy can be fatal and there are no clearly defined risk
factors to predict its onset, all patients should be informed of this serious albeit
rare complication. From our own institutional experience, SI was not routinely
discussed with the patient during the consent process. There have been lawsuits
reported in Italy involving SI post-colonoscopy.16,17 For both the patient’s
understanding of the inherent risks of a minimally invasive procedure and
medicolegal obligations, the endoscopist should make an effort to discuss this rare
but potentially fatal complication with his or her patient.

Conclusion
SI is an infrequent yet underrecognized complication of colonoscopy. The presentation
may be nonspecific, and the risk factors remain elusive. A physician’s clinical
acumen is key in formulating the diagnosis. Patients undergoing colonoscopy should
be informed about this rare but severe complication given its unpredictable nature
and potential medicolegal consequences.

We thank Dr. Claudia Lapidus for providing radiological review of this case.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.

Ethical approval: Ethical approval to report this case was obtained from New York
Presbyterian-Brooklyn Methodist Hospital

Funding: The author(s) received no financial support for the research, authorship, and/or
publication of this article.

Informed consent: Written informed consent was obtained from the patient(s) for their anonymized
information to be published in this article.

ORCID iD: Allison N Zhang 
https://orcid.org/0000-0002-9486-6520
==== Refs
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