A case report of delayed intra-abdominal and intra-luminal haemorrhage after polypectomy

Abstract

We report the case of a 70-year-old man who presented with hematochezia, anaemia, and severe abdominal pain 6 days after polypectomy. Contrast-enhanced ultrasound and computed tomography revealed no signs of free intra-abdominal air but showed intra-abdominal and intra-luminal bleeding. The patient was referred to colonoscopy in the operation room, which showed a coagula and venous bleeding at the polypectomy site. Emergency laparotomy was performed and revealed a large intra-abdominal mesocolic hematoma, which was surgically removed. The patient’s post-operative recovery was uneventful. While few reports of splenic vessel rupture after colonoscopy due to traction on the splenocolic ligament have been published, delayed mesocolic hematoma without evidence of organ damage has not been reported so far. Clinicians need to be aware of these rare but life-threatening complications following colonoscopy.

Zusammenfassung

Wir berichten über einen 70-jährigen Patienten, der sich aufgrund einer neu aufgetretenen Hämatochezie, Anämie und abdominellen Schmerzen sechs Tage nach erfolgter Koloskopie und Polypektomie notfallmäßig vorstellte. Die Kontrastmittelsonografie und die Computertomografie zeigten keine Hinweise auf eine Perforation, jedoch Zeichen eines großen intra-abdominellen Hämatoms. Koloskopisch zeigte sich eine leichte Sickerblutung an der Polypektomiestelle ohne Nachweis einer weiteren intraluminalen Blutung. Die nachfolgend durchgeführte Notfall-Laparotomie wies ein großes intraabdominelles mesokolisches Hämatom nach, welches erfolgreich ausgeräumt werden konnte. Der postoperative Verlauf gestaltete sich komplikationslos. Es existieren einzelne Fallberichte über unmittelbare Milzgefäßverletzungen nach ausgeübter Traktion des splenokolischen Ligaments im Rahmen der Koloskopie, jedoch gibt es bisher keine Berichte über das Auftreten eines verspäteten mesokolischen Hämatoms. Endoskopiker sollten sich dieser seltenen, aber potentiell lebensbedrohlichen Komplikation bewusst sein.

Schlüsselwörter

Gastrointestinale Blutung - Koloskopie - Intrabdominelle Blutung

Key words

gastrointestinal bleeding - colonoscopy - intra-abdominal bleeding

• References

• 1 Crispin A, Birkner B, Munte A. et al. Process quality and incidence of acute complications in a series of more than 230000 outpatient colonoscopies. Endoscopy 2009; 41: 1018-1025
• 2 Rutter CM, Johnson E, Miglioretti DL. et al. Adverse events after screening and follow-up colonoscopy. Cancer Causes Control 2012; 23: 289-296
• 3 Singla S, Keller D, Thirunavukarasu P. et al. Splenic injury during colonoscopy – a complication that warrants urgent attention. J Gastrointest Surg 2012; 16: 1225-1234
• 4 Shankar S, Rowe S. Splenic injury after colonoscopy: case report and review of literature. Ochsner J 2011; 11: 276-281
• 5 Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc 2001; 15: 251-261
• 6 Repici A, Hassan C, De Paula PD. et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44: 137-150
• 7 Hui AJ, Wong RM, Ching JY. et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 2004; 59: 44-48
• 8 Heldwein W, Dollhopf M, Rosch T. et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005; 37: 1116-1122
• 9 Watabe H, Yamaji Y, Okamoto M. et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 2006; 64: 73-78
• 10 Buddingh KT, Herngreen T, Haringsma J. et al. Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol 2011; 106: 1119-1124
• 11 Sawhney MS, Salfiti N, Nelson DB. et al. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 2008; 40: 115-119
• 12 Lee CK, Shim JJ, Jang JY. Cold snare polypectomy vs. Cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study. Am J Gastroenterol 2013; 108: 1593-1600
• 13 Nakajima T, Saito Y, Tanaka S. et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262-3270
• 14 Swan MP, Bourke MJ, Alexander S. et al. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointest Endosc 2009; 70: 1128-1136
• 15 Moss A, Bourke MJ, Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918
• 16 Luigiano C, Consolo P, Scaffidi MG. et al. Endoscopic mucosal resection for large and giant sessile and flat colorectal polyps: a single-center experience with long-term follow-up. Endoscopy 2009; 41: 829-835
• 17 Conio M, Repici A, Demarquay JF. et al. EMR of large sessile colorectal polyps. Gastrointest Endosc 2004; 60: 234-241
• 18 Liaquat H, Rohn E, Rex DK. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc 2013; 77: 401-407
• 19 Dominitz JA, Eisen GM, Baron TH. et al. Complications of colonoscopy. Gastrointest Endosc 2003; 57: 441-445
• 20 Salvador ME, Lorente PS, Arroyo Villarino MT. et al. Hemoperitoneum as a complication of diagnostic colonoscopy. Gastroenterol Hepatol 1999; 22: 377
• 21 Gonzalez-Rodriguez JF, Tarquis-Alonso P, Castano-Pascual A. et al. Hemoperitoneum due to necrosis of a small intestinal leiomyosarcoma following colonoscopy. Endoscopy 1993; 25: 253-254
• 22 Sorrentino M, Terrosu G, Risaliti A. et al. Hemoperitoneum caused by lesions to the appendix epiploica. An unusual complication of colonoscopy. Minerva Chir 1996; 51: 835-837
• 23 Choudari CP, Rajgopal C, Palmer KR. Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment. Gut 1994; 35: 464-466
• 24 Kaplan RC, Heckbert SR, Koepsell TD. et al. Risk factors for hospitalized gastrointestinal bleeding among older persons. Cardiovascular Health Study Investigators. J Am Geriatr Soc 2001; 49: 126-133
• 25 Sanjay P, Kellner M, Tait IS. The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy. HPB (Oxford) 2012; 14: 812-817
• 26 Baker TA, Aaron JM, Borge M. et al. Role of interventional radiology in the management of complications after pancreaticoduodenectomy. Am J Surg 2008; 195: 386-390