Hemoperitoneum after colonoscopy

Colonoscopy is the primary screening procedure for colorectal cancer and carries very low risk of complications (between 0.3 % and 0.35 %) [1]. It is estimated that 1.69 million colonoscopies are performed each year in the USA alone [2]. The most common complications are intraluminal gastrointestinal bleeding and colonic perforation [1]. Infrequently, hemoperitoneum occurs, mostly involving damage to the spleen. We present a case of hemoperitoneum following colonoscopy without splenic injury.

A 59-year-old female presented to our emergency department following a syncopal episode 12 hours after an unremarkable screening colonoscopy. Despite minor abdominal discomfort noted after the procedure, she resumed her normal activities. Pertinent history included a prior appendectomy. Besides pallor and minimal abdominal tenderness to palpation, physical exam was within normal limits. Laboratory tests showed a hemoglobin concentration of 10.4 g/dL and a hematocrit of 28.8 %. Leukocyte count, electrolytes, blood urea nitrogen, and creatinine were normal. Stool was guaiac negative. An abdominal radiograph excluded pneumoperitoneum ([Fig. 1]). Computed tomography (CT) scans of the abdomen and pelvis showed moderate amounts of free fluid demonstrating a density level suggestive of blood. The spleen appeared normal and there was no free air or extravasation of contrast from the bowel ([Fig. 2 a, b]). She was monitored for further bleeding and was subsequently discharged after 6 days.

Fig. 1 Abdominal radiograph centered at the diaphragm excludes the presence of pneumoperitoneum.

Fig. 2 Contrast-enhanced axial computed tomography images of (a) abdomen and (b) pelvis show intact spleen and free fluid with density measurements compatible with blood.

Intra-abdominal hemorrhage, a rare complication of colonoscopy, is most commonly reported in conjunction with splenic injury. Other documented causes of hemoperitoneum after colonoscopies include a torn mesenteric vessel, a ruptured epiploic appendix, and a necrosed intestinal leiomyosarcoma [3] [4] [5]. Due to the lack of other findings, it was speculated that the etiology in this case was a torn mesenteric vein. Intra-abdominal adhesions from her appendectomy could have contributed.

Endoscopy_UCTN_Code_CPL_1AJ_2AB

References

• 1 Dominitz J A, Eisen G M, Baron T H. et al . Complications of colonoscopy.  Gastrointest Endosc. 2003;  57 441-445
• 2 Vijan S, Inadomi J, Hayward R A. et al . Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States.  Aliment Pharmacol Ther. 2004;  20 507-515
• 3 Salvador M E, Lorente P S, Arroyo V M. et al . Hemoperitoneum as a complication of diagnostic colonoscopy.  Gastroenterol Hepatol. 1999;  22 377
• 4 Sorrentino M, Terrosu G, Risaliti A. et al . Hemoperitoneum caused by lesions to the appendix epiploica. An unusual complication of colonoscopy.  Minerva Chir. 1996;  51 835-837
• 5 Gonzalez-Rodriguez J F, Tarquis-Alonso P, Castano-Pascual A. et al . Hemoperitoneum due to necrosis of a small intestinal leiomyosarcoma following colonoscopy.  Endoscopy. 1993;  25 253-254