Critical Care NetWork Puzzler - May 2010

Splenic rupture

Case report:
A 59 year-old man came to your office for an elective colonoscopy. Past medical history is significant for end-stage renal disease on hemodialysis, coronary artery disease, diabetes mellitus, and multiple polypectomies during previous uncomplicated colonoscopies. He received meperidine and midazolam for the procedure, during which four polyps were removed using routine techniques. No bleeding was noted endoscopically. The patient remained stable throughout the procedure; however, in the recovery area, he noted significant epigastric abdominal pain with radiation to the back. He developed profound hypotension with cool extremities. Initial abdominal exam was soft with diffuse tenderness to palpation and hypoactive bowel sounds; no peritoneal signs were present. He was urgently transferred to the ICU for stabilization, volume resuscitation, and ultimately, vasopressors. Initial postprocedural laboratory findings showed a hemoglobin level of 6.2 gm/dL, down from preprocedure value of 11 gm/dL. Serial abdominal exams showed increasing distention and rigidity with development of peritoneal signs. CT scan of the abdomen demonstrated a tear in the splenic capsule with extensive intraperitoneal blood (Fig 1).

Figure 1. CT scan of the abdomen.

The patient was urgently taken to the operating room for exploratory laparotomy. Continued splenic bleeding was noted, and a splenectomy was performed. The postoperative course was uncomplicated, and the patient was discharged to home on postoperative day seven.

Discussion:
Splenic rupture is a rare complication of colonoscopy¹; however, it must be considered in the differential diagnosis of a patient presenting with severe abdominal pain and shock following the procedure. The mechanism by which splenic rupture occurs is not yet fully understood, but partial splenic capsular avulsion is most commonly seen.² Increased risk for splenic injury can be derived from both procedural and patient-related factors. Procedural risk factors include excessive traction on the splenocolic ligament, the supine position, and polypectomy.³ Interestingly, many splenic injuries have occurred in reportedly “easy” colonoscopies.² Patient-related risk factors revolve around anything that increases splenocolic adhesions. These include previous abdominal surgeries, repeated colonoscopies, splenomegaly, inflammatory bowel disease, and pancreatitis.^2,4 Frequently, chest and abdominal radiographs are normal; thus, CT scan is the imaging modality of choice for both the diagnosis and extent of splenic injury.² Once the diagnosis of splenic rupture is made, conservative treatment vs surgical intervention should be determined by standard surgical algorithms based on the grade of injury.¹ Although rare, splenic rupture can be deadly and should be considered early in patients who present with abdominal pain following colonoscopy.

References

1. Luebke T, Baldus SE, Holscher AH, Monig SP. Splenic rupture: an unusual complication of colonoscopy. Surg Laparosc Endosc Percutan Tech. 2006;16:351-354.
2. Espinal EA, Hoak T, Porter JA, Slezak FA. Splenic rupture from colonoscopy: a report of two cases and review of the literature. Surg Endosc. 1997;11:71-73.
3. Tse CC, Chung KM, Hwang JS. Splenic injury following colonoscopy. Hong Kong Med J. 1999;5:202-203.
4. Al Alawi I, Gourlay R. Rare complication of colonoscopy. ANZ J Surg. 2004;74:605-606.