Hemoperitoneum due to Splenic Laceration Caused by Colonoscopy: A Rare and Catastrophic Complication

Numerous studies suggest that in asymptomatic patients, routine follow-up CT is not indicated due to the insignificant findings found on these patients. A 53-year-old man, who denied any underlying disease before, underwent colonoscopy for routine health examination. Sudden onset of abdominal pain around left upper quarter was mentioned at our emergency department. Grade II spleen laceration was found on CT scan. Splenic injury was found few hours later on the day of colonoscopy. It might result from the extra tension between the spleen and splenic flexure which varies from different positions of patients. 1. Background Colonoscopy is a relatively safe procedure for the diagnosis and treatment. The major complications are bleeding, which is 4.8 per 1000 colonoscopies mostly after biopsy and polypectomy, and perforation, which is 0.9 per 1000 colonoscopies, mostly due to excessive looping and overdistension of cecum [1]. Splenic injury is a rare and catastrophic consequence after colonoscopy. Approximately 66 cases have been reported in the literature to date [2]. The mechanism of splenic injury followed by colonoscopy is believed due to the stretching splenocolic ligament that resulted from the movement of colonoscope or the formation of loop at the splenic flexure [3]. Developed adhesions between splenic flexure of colon and spleen would increase the immobility of spleen. Such adhesion could result from prior abdominal surgery, inflammatory bowel disease, and pancreatitis. Additional traction on splenocolic ligament could be exerted by the external compression on the left side of abdomen,in order to prevent the loop formation of colonoscope. Such movement on a patient with adhesion between spleen and splenic flexure would increase the risk of splenic injury. Other risk factors include difficult insertion, looping inside left colon, and splenomegaly [3]. However, splenic injury could cause mortality if not diagnosed earlier. In the clinical presentation of splenic injury, abdominal pain is the most common sign, which could be mistaken for common abdominal discomfort due to distension of colon. Referred pain to left shoulder, which is called Kehr’s sign, could be presented. It is highly sensitive but not specific that it also can be presented in a patient after an uncomplicated colonoscopy [4]. A CT grading system for splenic injury was developed by the American Association for the Surgery of Trauma (AAST) to classify severity of splenic injury [1]. Controversy exists regarding appropriate nonoperative management of splenic injury depending on imaging