A Woman With Dizziness and Shoulder Pain After Colonoscopy

Saad A. Shebrain, MD; Patrick Knight, MD


May 03, 2023

The hallmark procedural complications related to colonoscopy include postpolypectomy syndrome (PPS), lower gastrointestinal (GI) bleeding, and colonic perforation. PPS occurs secondary to transmural bowel wall injury that results from electrocautery used during polypectomy. This leads to peritonitis surrounding the area of injury and subsequent pain. Patients who develop PPS typically present with mild abdominal pain related to the location of polyp removal within 24 hours of colonoscopy with performed polypectomy.[6,7] Reported rates of the development of this condition widely vary in the literature.

One large retrospective case-control study involving 47,083 patients was compiled with a goal of identifying potential risk factors of developing this PPS.[7] In this study, the incidence of PPS was 0.07%. Multivariate analysis of the reported patient population revealed that patients with hypertension, larger lesion size, and nonpolypoid lesion configuration were independent risk factors for the development of PPS. Notably, no mortalities were related to PPS in this large patient population. In mild cases, PPS can often be treated in an outpatient setting with oral antibiotics and limitation of oral intake to clear liquids for a short period of time.[8]

Postprocedural bleeding and visceral perforation are two rare, but potentially life-threatening, adverse outcomes. Rates of bleeding following colonoscopy have been reported in the range of 0.021% to 0.6%.[4,5] Bleeding can occur immediately following the procedure or may present in a delayed pattern days later.[4] In the case presented here, the patient most likely developed splenic injury with hematoma that was initially contained and then progressed over time to a frank splenic rupture, due to the severity of injury. Kehr's sign, which was present in this patient, is left shoulder pain related to diaphragmatic or splenic referred pain. Kehr's sign is commonly present in cases of splenic rupture after colonoscopy.[9]

Colonoscopy-related perforation affects around 1-8 per 10,000 procedures.[4,5] As expected, the rates of these complications are significantly higher secondary to colonoscopies in which polypectomies are performed.[3,4,5] Colonoscopies performed at ambulatory centers and those performed by lower volume endoscopists have also been found to be associated with a greater risk for the development of a perforation or bleeding.[3] In cases of perforation, prompt recognition and surgical consultation is imperative in order to achieve the best possible outcome.


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