A Woman With Dizziness and Shoulder Pain After Colonoscopy

Saad A. Shebrain, MD; Patrick Knight, MD

Disclosures

July 31, 2020

The patient in this case was taken to the operating room following the transfusion of an additional two units of packed red blood cells. Open versus laparoscopic evaluation and correction of her splenic rupture were discussed. Because of the patient's relative stabilization from a hemodynamic standpoint, the decision was made to proceed with a laparoscopic splenectomy. This was accomplished using 4 port insertion points created through a supraumbilical incision, as well as one incision in the left upper quadrant, left lower quadrant, and the right upper quadrant. Upon entry, a significant amount of fresh and old clot was identified in the left upper quadrant, with 2 liters suctioned in total.

Upon further examination, a grade IV splenic laceration was identified. The splenocolic ligament was taken down using an electrocautery vessel sealing device, as were the short gastric vessels. The splenic artery was isolated and transected using a vascular stapler with subsequent transection of the splenic vein in a similar fashion. The splenic tissue was retrieved using endoscopic bag. The entire intraperitoneal space was then visualized with suctioning of residual blood. During this evaluation, a significant amount of intra-abdominal adhesions were identified involving the lower abdomen and pelvis. From first incision to final closure, the procedure took 40 minutes to perform (see Figure 3).

Figure 3.

The patient progressed well postoperatively with serial lab work that revealed stabilization of her hemoglobin. She was ultimately discharged on postoperative day 6 and given the necessary vaccinations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.

Although the incidence of splenic injury after colonoscopy is difficult to assess because most cases go unnoticed, clinically significant splenic laceration and rupture has been reported in the literature; however, fewer than 100 cases have been reported.[10,11] However, this may be due to underreporting.[12] Three potential mechanisms for splenic injury during colonoscopy have been postulated[13,14,15,16]:

  • Excessive traction on the splenocolic ligament

  • Traction on preexisting splenocolic adhesions from previous abdominal surgeries or inflammation

  • Direct splenic trauma as the endoscope traverses the splenic flexure, secondary to transcolonic pressure, looping, or external pressure used to straighten the scope

This case represents an excellent medium to discuss colonoscopic complications that are more likely encountered in day-to-day practice.

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