splenic injury during colonoscopy—a complication that warrants urgent attention

ORIGINAL ARTICLE

Splenic Injury During Colonoscopy—a Complicationthat Warrants Urgent Attention

S. Singla & D. Keller & P. Thirunavukarasu &

D. Tamandl & S. Gupta & J. Gaughan & D. Dempsey

Received: 31 December 2011 /Accepted: 7 March 2012 /Published online: 27 March 2012# 2012 The Society for Surgery of the Alimentary Tract

AbstractIntroduction Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small butsignificant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosismay be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensivereview of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation andmanagement of this rare but potentially life-threatening complication.Materials and Methods A comprehensive literature search identified 102 patients worldwide, including patients from ourexperience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalizedlinear model for repeated measures to identify risk factors for this rare complication.Results A total of 75 articles were identified and 102 patients were studied. The majority of the papers were inEnglish (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reportedafter the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %),median age was 65 years (range, 29–90 years), and most of the colonoscopies were performed without difficulty(66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain todizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive toolfor diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemo-globin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortalityrate was 5 %.Conclusion Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality.Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation iswarranted.

S. Singla (*) :D. KellerDepartment of Surgery, Temple University Hospital,3401 N. Broad Street, 4th Floor Parkinson Pavilion,Philadelphia, PA, USAe-mail: [email protected]

J. GaughanDepartment of Physiology, Temple University Hospital,Philadelphia, PA, USA

P. ThirunavukarasuDepartment of Surgery, University of Pittsburgh Medical Center,Pittsburgh, PA, USA

D. TamandlDepartment of Surgery, Memorial Sloan-Kettering Cancer Center,New York, NY, USA

S. GuptaBharati Vidyapeeth Deemed University,Pune, India

D. DempseyDepartment of Surgery,Hospital of the University of Pennsylvania,Philadelphia, PA, USA

J Gastrointest Surg (2012) 16:1225–1234DOI 10.1007/s11605-012-1871-0

Keywords Spleen injury . Splenectomy . Colonoscopy

Introduction

In the USA, nearly 14 million colonoscopies are performedannually.1 While colonoscopy is considered a safe proce-dure that is performed routinely, there is the risk of adverseevents, most commonly hemorrhage (1 %) and perforation(0.1 %).2 A small but significant complication resultingfrom colonoscopy is splenic injury, the incidence of whichis estimated at between 0.00005 and 0.017 %.3 Because ofits rarity and lack of awareness, the diagnosis may bedelayed, which can lead to an increased risk of morbidityas well as mortality.2

The first case of splenic injury after colonoscopy wasdescribed by Wherry and Zehner in 1974.4 While additionalcases have since been published, most of the availableinformation is based on case reports and case series. It islikely that the true incidence of this complication is under-estimated and underreported. The purpose of his paper is topresent a comprehensive review of the available medicalliterature on colonoscopy-associated splenic injury. Wesummarize the reported patient presentation, diagnosis,management and treatment, and potential risk factors asso-ciated with this complication. We also propose recommen-dations regarding the approach to this infrequent life-threatening problem and revisit the calculated incidenceusing the National Inpatient Sample. The main study out-comes are reports on incidence, treatment options, and mor-bidity and mortality associated with this complication.

Materials and Methods

A comprehensive search was conducted to identify literaturepublished worldwide describing splenic injury secondary tocolonoscopy. There were no time or language constraintsduring our literature search. Keywords used in the searchincluded “spleen injury”, “splenectomy”, and “colono-scopy”. Reference lists from prior articles were reviewedto identify further pertinent articles. One hundred patientswere identified from 75 articles and two additional patientswere added from our own experience for a total of 102patients (Table 1).6, 11–13, 17–86

We performed a meta-regression using demographics,predisposing risk factors, presentation, diagnosis, manage-ment, and post-injury course in these patients. A mixedgeneralized linear model for repeated measures was usedfor the meta-regression with patient and treatment character-istics modeled as fixed factors and studies as a randomfactor. The random study effect was chosen to accommodateassumed heterogeneity of the studies.

Results

Literature

A total of 78 studies initially identifying 111 patients were foundduring our literature search. Of these, 75 studies with demo-graphic and clinical information on 100 patients were foundpertinent to our study. Sixty-nine papers were published inEnglish, while six were non-English and translated to retrieverelevant information. Geographically, 39 studies originated in theUSA, 24 from Europe, five from Australia and New Zealand,four fromAsia, two from Canada, and one from South America.

Demographic Profile

Among the 102 patients included in our study, there was asignificantly higher number of injuries reported amongfemales (n078, 76.5 %) as compared to males (n024,23.5 %). The median age for all patients was calculated at65 years (range, 29–90 years). Only 23.4 % of patients (26/102) were reported prior to the year 2000. In the casesreported after the year 2000, a vast majority (84.2 %, 64/76) were published after 2005.

Incidence

To estimate the true occurrence of splenic injury secondaryto colonoscopy, we utilized the 2000–2007 US HealthcareCost and Utilization Project-sponsored Nationwide Inpa-tient Sample data. We searched all cases containing ICD-9codes for both closed spleen injuries (ICD-9 codes: 865.00,.01, .02, .03, .04, .09) and in-patient colonoscopies (ICD-9code: 45.23). Using these data, we calculated the weightednational incidence rate for each year (Table 2).

Risk Factor

At the time of the procedure, 11 patients (10.8 %, 11/102)were found to be taking anti-platelet medications or bloodthinners. Another group of 11 patients (10.8 %, 11/102)were noted to have evidence of inflammatory bowel disease.On review of prior intra-abdominal surgery, we found infor-mation available on 85 patients (no information regardingsurgery on 17 patients). Of these, 41 patients (48 %) hadhistory of prior surgery. Among these, 16 patients (females)had pelvic surgery and only seven patients (17 %) werenoted to have any previous colorectal operation (presumedhigh risk for development of colo-splenic adhesions).

Procedure

The motivation for undergoing colonoscopy was routinescreening in 29 patients and diagnostic study in 69 patients

1226 J Gastrointest Surg (2012) 16:1225–1234

Table 1 List of characteristics, presentation and findings in patients sustaining splenic injury during colonoscopy6, 11–13, 17–86

Year Gender Difficultcolonoscopy

Time to presentationin days

Hb drop >3 g/dl Splenectomy Readmission Death

1977 F + 3 +

1979 F 1 + +

1984 M 1 + +

1986 F 1 +

1986 M 1 + + +

1987 F 1 +

1987 F 1 + +

1987 F 1 + +

1989 F 1 +

1989 F 10 + +

1990 M 1 +

1990 F 1 +

1991 M + 1 + +

1991 F + 6 + +

1992 M + 1 + +

1993 F + 1 + +

1994 M 6

1997 F 3 +

1997 F 4 + +

1997 F 1 + + +

1997 F 1 + +

1997 F 1 + +

1999 M 2 + +

1998 F + 1

1999 F 1

1999 F 1 +

2002 M 2 +

2003 F 4

2003 M + 20 +

2004 F + 1 + +

2004 F 1 +

2004 F 1 + +

2004 F 1 +

2004 F 1 + + +

2004 M 1 +

2004 F + 1 +

2004 F 1 +

2004 F 4

2005 F + 5 +

2005 F 7 +

2005 F 2 +

2005 M + 1 +

2005 F 1 + +

2005 F 1 + +

2005 F + 1 + +

2006 F 4 +

2006 F 1

2006 F 1 + +

J Gastrointest Surg (2012) 16:1225–1234 1227

Table 1 (continued)




2006 F 120 +

2006 F 1 +

2006 M 1 + +

2007 M 1 + +

2007 M NA + +

2007 F 1 + +

2007 F 5 +

2007 F 1 +

2008 M 1 +

2008 F + 1 + +

2008 M 6 +

2008 F + 7 +

2008 F 1 +

2008 F + 1 +

2008 F 1 + +

2008 F + 1 +

2007 F 1 +

2008 F 2

2008 M 1 + +

2008 F 1 + +

2008 F 45 +

2008 M + 2 +

2008 F 1 +

2008 F 1

2008 F 1

2008 F 1

2008 F 2

2008 F + 2 +

2008 F 1

2009 M 2 + +

2009 F 1 +

2009 M + 1 +

2009 M 1 + +

2009 F + 1 + +

2009 F 1 + +

2009 F 2 +

2009 F 1 + +

2009 F 1 +

2009 F 1 + +

2009 F + 1

2009 F 1

2009 F 1 + +

2009 F 1 +

2009 F 6 + +

2010 F 1 + +

2010 M 1 +

2010 F 1 + +

2010 F + 2 + + +


(data available, n098), respectively. Thirty-seven patientsunderwent a colonoscopic procedure: 28 patients had poly-pectomy and nine patients had biopsy. On survey aboutdifficulty during the procedure, majority of the patients(n068) had normal colonoscopy, with physicians reportingno difficulty noted during the procedure. Among thepatients with difficulty noted, only three patients had anyprocedure done (polypectomy or biopsy).

Presentation

The majority of patients (67.6 %) presented within 24 h(range, 1–120 days) of completion of colonoscopy with com-plaints ranging from abdominal pain to syncope and dizziness.The most common symptom at presentation was left upperquadrant pain (58%), while abdominal pain and dizziness wasnoted in 17 %, diffuse abdominal pain in 15 %, and dizzinessalone in 10 % of patients. On physical exam, Kehr sign(referred pain at left shoulder tip) was positive in 56 % ofpatients (information available on 79 patients only). Duringour analysis, we also noted that 11 patients (10.8 %) presenteda second time with similar complaints after discharge at anearlier visit after colonoscopy. We found that these patientswere discharged at the time of their first visit due to lack ofknowledge about this complication.

Among the patients with data available regarding fall inthe value of hemoglobin, nearly 69 % of patients had a

significant drop in hemoglobin (>3 gm/dL) from the timeof initial presentation. Within this sub-group of patients,73 % of patients received blood transfusion; however, morethan 29 % of patients required more than three units ofblood to maintain hemodynamic stability.

Diagnosis

The initial investigational studies including plain radiographs,ultrasound, and peritoneal lavage were reported normal innearly 42% of patients admittedwith splenic injury. However,due to a high clinical suspicion for a significant intra-abdominal injury, these patients underwent further investiga-tions including CT scan, which confirmed the diagnosis. Ourreview revealed that CT scan was the most sensitive diagnos-tic tool, with reports of 100 % diagnostic sensitivity.

We noted that abdominal ultrasound and diagnostic peri-toneal lavage (DPL) were also utilized during the evaluationof these patients. We found that while the trend towardsutilizing the focused assessment with sonography for trauma(FAST) scan has been rising steadily, the reliance on DPLhas declined, especially in the last 5 years. We believe thatwith continued improvements in non-invasive investigation-al modalities, the use of DPL will decline further.

Treatment

Splenic injury was managed with operative intervention in71.5 % of patients (n073). There were few or no detailsprovided if any non-operative management was initiallyattempted or had failed in these patients. Of the 73 patientswho underwent operative intervention, 96 % of patients (n070) were treated with splenectomy, while three patientsunderwent splenic salvage procedures. The remaining 29patients (28.4 %) were managed non-operatively with eitherobservation and resuscitation or angiography and emboliza-tion. An increasing trend in non-operative management wasobserved in the reports after the year 2000 (22 of 29 patients(75.8 %) treated non-operatively). Among the four patientswho underwent angiographic embolization, three patientswere reported in the last 5 years. The overall mortality rate

Table 1 (continued)




2010 M 2 + +

2010 F 1 +

2010 M 2 + +

2010 F 1 + +

2011 F 7

2011 F 5 +

Table 2 Weighted national incidence of splenic injury with colono-scopy for each year, 2000–2007

Year Spleeninjuries

In-patientcolonoscopies

Rate per100,000

2000 45 314,118 14.33

2001 57 346,911 16.43

2002 45 336,755 13.36

2003 46 349,968 13.14

2004 56 359,865 15.56

2005 74 330,842 22.37

2006 49 317,897 15.41

2007 65 298,100 21.81


calculated for this complication was about 5 %. The deathswere found to be unrelated to any significant risk factor ortreatment intervention.

Meta-regression analysis (Table 3) was performed to iden-tify factors associated with operative intervention in thesepatients. The variables analyzed included age, gender, inflam-matory bowel disease, previous colorectal surgery, anticoagu-lation, time since presentation, difficulty of colonoscopy,hemoglobin drop greater than 3 gm/dL, and readmission.Based on the univariate analysis, the only significant predictorof operative intervention was a hemoglobin drop of more than3 gm/dL (p00.0239, odds ratio04.55, CI01.28–16.2).

Discussion

Splenic injury after colonoscopy is a serious complication, yetits true incidence is largely unknown. A number of authorshave presented reports regarding this complication, but itseems that not enough patients have been reported, as onemay believe, given the fact that this complication is associatedwith 5 %mortality rate. Smith mentioned only one case out of20,139 colonoscopies performed5; Ong reported one in 6,387patients,6 while Jentschura reported no splenic complicationsin almost 30,000 colonoscopies.7 If we compare the articlespublished worldwide, there are very few or no reports from themost populous regions of the world. We hypothesized that thetrue incidence was higher than the calculated rates. Whileprevious reviews have estimated the incidence at 0.00005 to0.017 %, we calculated a rate based on the 2007 NationalInpatient Sample as 21.81/100,000 (Table 2). Since our reviewdemonstrates this to be an under-recognized and under-reported injury, the true incidence remains unknown, butpresumably much higher. Also, given the quality of the dataand the studies available for our analysis, it is difficult toextrapolate from the database to the real incidence.

Our research shows a significantly higher percentage offemales injured with splenic injury during colonoscopy(nearly 76.5 %). This is in contrast and much higher thanthe number of females undergoing colonoscopy routinely.

Currently, depending upon the sub-set of population stud-ied, it is estimated that the percentage of females undergoingroutine colonoscopy varies between 43 % and 57 %.8–10

Therefore, it may be prudent to hypothesize that a highincidence of splenic injury during colonoscopy amongstfemales is not due to a higher number of females undergoingcolonoscopy but due to another cause that is not well un-derstood and needs to be studied further.

The presumed mechanisms leading to splenic injury dur-ing colonoscopy include direct trauma to the spleen, exces-sive spleno-colic ligament traction, and a decrease in therelative mobility between the spleen and the colon.11 Spe-cific maneuvers, such as the slide by advancement, alphamaneuver, hooking the flexure, and straightening the sig-moid loop, have been implicated in causing excessive trac-tion and splenic capsule avulsion.12 Partial capsularavulsion can also result from the colonoscope looping nearthe splenic flexure. Previous authors asserted that patientswith history of prior abdominal surgery, inflammatory bow-el disease, use of anti-platelet agents or blood thinners,difficulty during colonoscopy, and interventions such aspolypectomy during colonoscopy were at a higher risk fordeveloping splenic injury.13 However, our review found thatvery few patients who suffered from splenic injury had anyprior predisposing factors. Only 11 out of 102 patients werefound to be on prescription aspirin, clopidogrel, or warfarin.Further, only 11 patients had history of inflammatory boweldisease and about seven patients had any colonic surgery.

It has also been stated that positioning the patient in thesupine position increases the chances of splenic injury duringendoscopy as the force exerted on the spleen due to gravityand traction, respectively, oppose each other. To prevent ex-cessive traction, some authors recommend placing the patientsin the left lateral position during the entire procedure. How-ever, the literature review did not find any data to support thisassumption. Given the current aggressive approach in detect-ing colonic pathology early, it may be argued that the empha-sis on reaching the cecum is greater today than it was 15 or20 years ago, leading to more aggressive pushing/torqueing ofthe scope and leading to more splenic tears.

Table 3 Meta-regression resultsshowing predictors for operativeintervention

Effect Numerator DF Denominator DF f value p value Odds ratio 95 % CI

Age 1 25 0.53 0.472

Gender 1 25 0.13 0.720

IBD 1 25 0.02 0.8975

Colon surgery 1 25 0.57 0.4592

Anti-coagulation 1 25 0.24 0.6272

Scope difficulty 1 19 0.00 0.9875

Time 1 25 0.02 0.8982

Hb drop >3 1 10 7.07 0.0239 4.55 1.28–16.2

Readmission 1 25 0.53 0.4742


Most of these patients presented within 24 h of comple-tion of colonoscopy with a range of complaints that are verysimilar to those noted after routine colonoscopy. It is there-fore very difficult to identify patients with splenic injurybased on these findings alone. However, on analysis usingmeta-regression, a significant drop in hemoglobin (>3 gm/dL) (from the time of initial presentation) was a significantpredictor for operative intervention (p00.0239). Also, wenoted that 73 % of this sub-set of patients received bloodtransfusion to maintain hemodynamic stability. It may there-fore be diligent to consider this sub-group of patients as inhigh risk of splenic injury at the time of initial presentation.

A concerning finding noted during analysis was thatnearly 11 % of patients (n011) were readmitted after initialdischarge by a physician on their first visit after colono-scopy. It was revealed that, in the majority of such cases, thephysicians (primary care or emergency department physi-cian) were unaware of this complication, attributing thepresenting symptoms to routine insufflation during the pro-cedure. Further, amongst patients who were admitted at thetime of initial presentation for further investigations, manyphysicians were stumped at the “surprise” finding of splenicinjury after colonoscopy. This clearly was indicative of ournotion that there is paucity of information regarding thiscomplication.

Based on these findings, there are no statistically signif-icant predisposing factors that increase the likelihood ofdeveloping colonoscopy-induced splenic injury. However,a small sample size may account for the lack of significance.Nonetheless, precautions may be taken to safeguard patientswho may be at higher risk. For example, some authorsroutinely admit patients for observation after a difficultprocedure such as a large polypectomy or a difficultcolonoscopy.13 If discharged home, patients were instructedto return for evaluation if they experienced any significantabdominal discomfort, dizziness, or syncope or developed afever within a few days after the colonoscopy. Incorporatingsuch guidelines, including early surgical consult and FASTexam for pain out of proportion to the procedure, will help

in preventing the delay in diagnosis of this potentially life-threatening complication.

Our results demonstrate that CT is the most sensitivediagnostic tool. We found that CT scan was conclusive inall patients who underwent CT scan as the initial study ofinvestigation as well as in the majority of patients who hadanother study done initially for diagnosing this injury.The other modalities used during the evaluation ofpatients included ultrasound and DPL. It was noted thatthere was an increase in the trend towards using theFAST14 scan for evaluation of such patients, especiallyin the last 5 years, while the reliance on DPL seemed tobe declining.

In light of recent literature regarding management ofblunt splenic injuries, we propose that patients presentingwith suspected splenic injury after colonoscopy be managedin parallel with the trauma literature. An initial ultrasoundearly in the course of evaluation can identify free fluid in theabdomen.14 In hemodynamically stable patients, further in-formation can be supplemented by performing a contrast-enhanced CT scan, which can not only increase the accuracyof diagnosing splenic injury to nearly 98 % but also allowsfor grading of splenic injury, detection of contrast “blush”,and identification of other concomitant injuries.15, 16 Basedon the findings of the CT scan, the splenic injuries can begraded according to the American Association of Surgeonsfor Trauma (AAST) Splenic Injury Grading Scale15 (Table 4).This grading scale can help differentiate patients whoare potential candidates for non-operative management.According to Boscak et al., all hemodynamically stablepatients with any grade of splenic injury and no otherinjuries requiring surgery are potential candidates forsplenic embolization.16 However, patients with AASTgrade III or higher injury, patients requiring transfusionin excess of one unit in the first 24 h with AAST III orhigher injury or large-volume hemoperitoneum or CTidentification of active bleeding or contained intra-splenic vascular injury are at increased risk of failingnon-operative management.16

Table 4 American Association of Surgeons for Trauma Splenic Injury Grading Scale15

Grade Injury description

I Hematoma Subcapsular, <10 % surface area

Laceration Capsular tear, <1 cm parenchymal depth

II Hematoma Subcapsular, 10–50 % surface area; intraparenchymal, <5 cm diameter

Laceration 1–3 cm parenchymal depth; does not involve a trabecular vessel

III Hematoma Subcapsular, >50 % surface area or expanding; ruptured subcapsular or parenchymal hematoma

Laceration >3 cm parenchymal depth or involving trabecular vessels

IV Laceration Laceration involving segmental or hilar vessels and producing major devascularization (>25 % of spleen)

V Laceration Completely shattered spleen


Although these recommendations provide valuable triagecriteria, the actual decision to operate versus non-operativemanagement will depend upon the overall clinical conditionof the patient. The one absolute indication for surgicalintervention in patients with splenic injury is intractablehypotension referable to the spleen.

Conclusion

Splenic injury during colonoscopy is a rare complicationthat is reported sparsely in literature. Due to a relative lackof awareness about this complication, some patients may getdischarged at the time of initial presentation, which maylead to a delay in diagnosis and potentially influence mor-bidity and mortality. Based on our review of literature, wepropose that physicians should maintain a low threshold inpatients with significant abdominal pain after colonoscopyfor performing further investigations including FAST examand CT scan to rule out complex injuries, and early surgicalconsultation is suggested.

Patients with hemodynamic instability or ongoing trans-fusion requirements should be managed with prompt surgi-cal intervention; however, for patients who are stable, wepropose non-operative management in line with traumaliterature as dictated by the patient’s clinical condition.Given that there is a paucity of quality data available re-garding this complication, we believe that as the awarenessabout this injury will increase, more patients will be identi-fied, which will not only help in better understanding of thiscomplication but allow us to manage such patients better.

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splenic injury during colonoscopy—a complication that warrants urgent attention

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