A 77-year-old woman with a past surgical history of hysterectomy
presented to the Emergency Department with increasing lower abdominal and back
pain. A routine screening colonoscopy had been performed 8 hours previously;
the endoscopist had noted that the colon was tortuous, however no abnormality
had been seen.
Abdominal palpation demonstrated moderate generalized lower
abdominal tenderness. Her white blood cell count (WBC) was found to be elevated
at 24 × 109/L. An urgent computed tomography
(CT) scan revealed a fluid density mass in the pelvis ([Fig. 1]) and thickening of the sigmoid colon ([Fig. 2]). The spleen and liver were normal, and no
free air was visualized.
Fig. 1 Computed tomography (CT)
scan demonstrating significant retroperitoneal pelvic fluid without obvious
extension into the peritoneal cavity.
Fig. 2 Computed tomography (CT)
scan showing thick-walled rectosigmoid colon. Intraoperatively, there was an
area of full-thickness ischemic necrosis.
Laparotomy revealed a large retroperitoneal and retrorectal hematoma
with only minimal blood in the abdomen. Adhesions between the colon and vaginal
vault gave the rectosigmoid a tight S-shape, and a segment approximately
10 cm in length was ischemic. A branch of the superior rectal artery
that had been avulsed could be identified. It is likely that during her
colonoscopy, in the process of getting the ‘tight S’ into a shape
that the colonoscope could navigate, the artery gave way as it had less
resistance than the tight adhesions. Hartman’s procedure was
performed.
The most common complications of colonoscopy include hemorrhage
(0.2 % – 0.5 %) and perforation
(0.9 % – 0.1 %)
[1]
[2]. The presence of fluid in
the pelvis on CT scanning could make one think of a perforation; however, the
lack of free air would make a perforation unlikely and hemorrhage more likely.
Our patient remained hemodynamically stable because the bleeding remained
retroperitoneal, which provided some degree of tamponade.
The scenario of a patient presenting to the emergency department
after colonoscopy, particularly with abdominal tenderness, should make one very
suspicious of a complication.
Endoscopy_UCTN_Code_CPL_1AJ_2AB
