hemorrhage and perforation are the most common complications after colonoscopy occurring in less than 1% of patients and often associated with biopsy or polypectomy .
splenic injury or rupture is also an infrequent complication that is often forgotten and may require urgent surgical intervention .
the first case of splenic trauma after colonoscopy was described by wherry and zehner in 1974 , but the true incidence of this dreadful complication is probably underestimated .
there are 39 case reports in the english literature and at least 9 more in foreign publications ( table 1 ) .
we report a similar case of splenic rupture diagnosed 18 hours after colonoscopy , which required emergent splenectomy .
presentation , diagnosis , treatment , and potential risk factors are evaluated herein , as is a thorough review of the literature .
summary of 42 cases of splenic injury after colonoscopy details were not provided in some cases .
ct = computed tomography ; us = ultrasound ; acls = advanced cardiac life support .
an 82-year - old woman was admitted to the hospital for mild congestive heart failure and pneumonia .
her past history was significant for myocardial infarction and a left nephrectomy for transitional cell carcinoma via a left flank incision .
after a week of intravenous antibiotics for left lower lobe pneumonia and bacteremia , she began having diarrhea .
tests for clostridium difficile were negative , and the patient was diagnosed with antibiotic - associated diarrhea . during this period ,
her diarrhea became blood tinged , and her hemoglobin dropped by 3 g / dl .
no acute origin of bleeding was identified , and findings included severe diverticulosis in the left colon and internal hemorrhoids .
the postprocedure period was complicated by the onset of left upper quadrant abdominal pain accompanied by hypotension .
laboratory tests revealed an acute drop in hemoglobin from 9.6 g / dl to 6.8 g / dl .
the patient was transfused appropriately , and a computed tomographic scan ( ct ) of the abdomen and pelvis was ordered .
the ct confirmed a large left upper quadrant hematoma , consistent with a splenic rupture and associated hemoperitoneum .
the patient had persistent hypotension and acute anemia and therefore was taken to surgery for exploration .
a midline laparotomy was performed , and a large amount of intraabdominal blood was encountered from the left upper quadrant . a moderate number of adhesions were present at the splenic flexure associated with a large splenic capsular tear .
splenic injury after colonoscopy is a serious complication , yet its true incidence is unknown . numerous large series over the last 3 decades have demonstrated splenic trauma as a rare entity .
reluctance to publish morbidity information , the absence of complication codes for splenic injury after colonoscopy , and the fact that the procedure is infrequently followed by routine surgical exploration all contribute to its unknown incidence . despite this uncommon complication , knowledge of this serious consequence is the best aide to early diagnosis because outcomes can be fatal .
the cause of splenic complications after colonoscopy have not definitively been established , yet many risk factors have been proposed ( table 2 ) .
the most common theory involves tension of the splenocolic ligament from either excessive manipulative traction or decreased mobility of the spleen or colon from adhesions .
specific maneuvers like the slide by advancement , alpha maneuver , hooking the flexure , and straightening the sigmoid loop have all been implicated in excessive traction and splenic capsule avulsion .
any prior surgery , inflammation , or intraabdominal infection may lead to adhesions and decreased mobility leaving the left upper quadrant susceptible to splenic insult during colonoscopy .
it has been suggested that positioning the patient and minimizing external pressure may prevent splenic complications in higher risk cases .
the left lateral position may allow the spleen and flexure to fall left and lax , preventing the tension of the spleen that occurs when it falls back in the supine position . despite precautions
age does not appear to be a risk factor , because the age range for reported cases was 33 years to 90 years with a median age of 63 years .
however , a higher risk of splenic complications does appear to exist in women . in reported cases that included gender , 72% ( 29/40 ) of cases occurred in women .
it is unclear why there is a predominance of this complication in the female population ( table 3 ) .
proposed risk factors for splenic injury during colonoscopy case characteristics of splenic injury after colonoscopy us = ultrasound ; ct = computed tomography ; acls = advanced cardiac life support .
often early symptoms are attributed to postpolypectomy serositis , colonic distension , analgesia , sedation , old age , or impaired mental status . the differential diagnosis for significant pain within 24 hours after colonoscopy includes retained gas , perforation , and splenic injury .
rare complications causing abdominal pain include mesenteric tears , volvulus and gas explosions . pain less than 12 hours postprocedure will warrant observation in most cases . in 39 patients with recorded symptoms , 31 ( 79% ) presented with the onset of symptoms in less than 24 hours .
most patients present with abdominal pain , often in the left upper quadrant , that may radiate to the left shoulder . historically , kehr 's sign is pain at the tip of the left shoulder after bimanual palpation of the left upper quadrant with the patient in the trendelenburg position .
it is not a reliable sign , and a positive kehr 's sign or left shoulder pain was only recorded in 55% ( 16/29 ) of patients .
hypotension , anemia , or an elevated white blood cell count can also suggest a splenic injury .
any patients with peritoneal signs or hemo - dynamic instability should be treated with a high index of suspicion for surgical perforation or splenic injury .
although early onset of symptoms is common , delayed diagnosis even up to 10 days has been described as has a patient with serious splenic injury who was entirely asymptomatic .
the diagnosis of a surgical abdomen should be made on clinical grounds , yet the advancement of imaging technology can elucidate the equivocal or suspicious case .
a ct scan provides a definitive diagnosis and delineates the degree of injury that can often determine operative versus nonoperative management .
ct was included in the diagnostic algorithm in 62% ( 25/42 ) of cases , and 11 of these scanned patients avoided a laparotomy and improved with nonoperative management .
the use of ultrasound has been described in 5 cases , but 2 of these cases also included ct scans .
ct remains the best diagnostic tool to aid in management , because all patients ( 11/11 ) treated nonoperatively were scanned in their evaluation .
the goal of management in splenic injury after colonoscopy is nonoperative ; however , splenectomy may be difficult to avoid .
thirty cases ( 70% ) required splenectomy , including half diagnosed by ct , but these numbers benefit from publication bias and the pre - ct era .
janes suggested that predictors of failed conservative treatment include hemodynamic instability , underlying splenic disease , a grade iii traumatized spleen by ct , old age , and hemoperotineum .
one case of splenic artery embolization has been reported , but the definitive interventional treatment remains splenectomy .
two cases were diagnosed during emergent laparotomy , and one case was found during autopsy after the patient underwent severe shock .
splenic injury and rupture are rare complications of colonoscopy that must not be forgotten in the differential for postprocedural pain .
not using excessive maneuvers in high risk patients and having a high index of suspicion postprocedure will optimize outcomes .
 colonoscopy is a familiar and well - tolerated procedure and is widely used as a diagnostic and therapeutic modality by both gastroenterologists and surgeons . 
 although perforation and hemorrhage are the most common complications , splenic injury or rupture is a rare but potentially lethal complication . 
 we report a case of splenic rupture diagnosed 18 hours after colonoscopy , which required emergent splenectomy . 
 we also reviewed over 39 other cases of splenic rupture or injury after colonoscopy reported in the english literature . despite being an infrequent complication , splenic rupture warrants a high degree of clinical suspicion critical to prompt diagnosis . 
 most patients present with symptoms within 24 hours after colonoscopy , although delayed presentation days later has been described . 
 ct scan of the abdomen is the radiological study of choice to evaluate colonoscopic complications . 
 splenic injury can be managed conservatively or with arterial embolization depending on the extent of trauma , but splenectomy remains definitive management . 
 clinical criteria are the primary determinants in choosing operative therapy over observation 
 . herein , possible risk factors for splenic trauma during colonoscopy are identified , and clinical outcomes are evaluated . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION