Colonoscopy can (almost) kill you.
- Carlos E Costa Almeida
- 2 de fev. de 2018
- 3 min de leitura
The most simple and easy procedure can be catastrophic. No procedure/exam is free of complications, and some of these can be severe. Colonoscopy is one of those (demoniac) exams.
Colonoscopy is used for diagnosis and treatment since 1969. Although it has been used for more than 40 years, complications are uncommon (0,5% - 2,5%). The most frequent complications are intraluminal bleeding and perforation. However, other rarer complications can occur (≤0,0001%): splenic tear or rupture; retroperitoneal abscess; pneumothorax. Additionally there is another complication which is even rarer than the rarer ones. A second case was published last year in the International Journal of Surgery Case Reports by Wen-ko Tseng et al. from Taiwan. According to the authors the first case report of a similar complication was published in 1975 (1 case in 6290 colonoscopies).
Wen-ko Tseng report a case of a 79yo male patient submitted to colonoscopy for abdomen distension and obstipation. Procedure was uneventful and free of findings. However, 9h after colonoscopy the patient presented with severe abdominal distension, shock, and an haemoglobin drop of 5 g/dL. Orotracheal intubation was necessary, and an abdominal CT scan revealed massive hemoperitoneum apparently induced by an inferior mesenteric artery branch lesion, without pneumoperitoneum. Emergent angiography was performed, and a contrast leak from the right superior rectal artery was found. Arterial embolization with coils stopped the bleeding (Figure). Following the first 24h in ICU a progressive elevation of intra abdominal pressure was noted, leading to an abdominal compartment syndrome (ACS). Emergent laparotomy was performed finding 3000mL of blood and clots which were aspirated. Whole colon and rectum were viable, and a rectosigmoid mesentery tear was identified and sutured to avoid future complications. Oral intake was initiated on the 7th post-op day. Recovery was uneventful.
Mesentery tear (second case report) with rectal artery injury is an extremely rare complication following colonoscopy. CT scan is the gold standard exam to make an accurate diagnosis. Treatment of mesenteric vessels' bleeding is controversial. However, following the good results of selective arterial embolization for splenic trauma and low gastrointestinal bleeding, this seems to be a good treatment strategy as an alternative to laparotomy.
"We propose that patients with active mesentery bleeding who need laparotomy alternatively may be managed with transarterial embolization, particularly patients at high surgical risk."
Wen-ko Tseng et al.
How can this complication be explained? The authors present three reasons/factors. First, the sharp angle of both the rectosigmoid and splenic flexure explain the high incidence of injury at these levels. Secondly, the difficulty of performing the exam has been presented as a risk factor. Lastly, a low BMI may be a risk. Thin patients will have small amount of mesentery fat to work as protective/supportive cushion of mesentery vessels. Will this be an advantage of being fat? Should we all get fat to avoid this complication? The risk/benefit ratio of being fat will not be changed, I think.
In my view, this article highlights the fact that any procedure can have severe complications despite being relatively simple and/or easy to perform. Doctors and patients must both be aware of this fact. All procedures must be explained in detail to patients focusing possible complications. Explanations must be given by the doctor who is going to perform that particular procedure, so that patient's doubts can be correctly answered.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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