Imaging Pearls ❯ Colon ❯ Trauma
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- “Colonoscopy is one of the most commonly performed endoscopic procedures and remains the most commonly used screening modality method for colorectal cancer (CRC) screening in the USA. Although serious complications of fiberoptic colonoscopy are uncommon due to technical advances, due to increasing number of colonoscopy procedures, post-procedural complications are not uncommonly encountered in the routine clinical practice. Also, as some of the post-colonoscopy complications are life threatening, it is important to diagnose them early so that timely treatment measures can be taken to decrease mortality and morbidity.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “The NCCN Guidelines for CRC Screening currently recommend that screening for average-risk individuals beginning at 50 years of age [3]. The American Cancer Society (ACS) 2018 and US Preventive Services Task Force 2021 guidelines recommend that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability; and all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “The most common complications of optical colonoscopy are hemorrhage and large bowel perforation. Less common complications include splenic injury, postpolypectomy syndrome, appendicitis, and acute diverticulitis. Unusual complications of colonoscopy include pneumothorax, omental infarction, liver abscess, septicemia, mesenteric tears, intussusception, and colonic volvulus.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - Complications of Colonoscopy
- hemorrhage
- Large bowel perforation.
- splenic injury
- postpolypectomy syndrome
- appendicitis, and acute diverticulitis - “Post-colonoscopy bowel perforation is a rare but serious complication of diagnostic colonoscopy and occurs in 0.005 to 1% of cases. Colonoscopy done for therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures is associated with higher rate of perforation and can be seen in up to 3% of patients.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “The most common site for diagnostic colonoscopy perforation is the sigmoid colon due to acute angulation of the rectosigmoid junction. As diverticular disease and polyps more commonly affect the sigmoid colon, the incidence of mechanical and thermal injury in the sigmoid colon is higher.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Intraluminal bleeding as a complication of optical colonoscopy typically occurs after a biopsy and polypectomy and is only rarely seen in the setting of a purely diagnostic examination. The incident of postpolypectomy bleeding ranges from 0.001–2%. Intraluminal bleeding can also result from inadvertent biopsy of a vascular lesion such as hemangioma, arteriovenous malformation, or a prominent mucosal vein associated with angiodysplasia.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Postpolypectomy bleeding can be classified as immediate (intraprocedural or within 24 h of the examination) or delayed (between 1 to 14 days after the examination). Polyp-related risk factors for postpolypectomy bleeding include polyp size, location, and morphology. Right-sided polyps have increased risk of bleeding after a polypectomy compared to the left-sided polyps due to thinner bowel wall in the right hemicolon and the close proximity of submucosal vessels to colonic mucosa . The larger size of the polyp (1 cm or larger), sessile polyps, and polypectomies in patients on anticoagulants increase the risk of postpolypectomy bleeding.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Splenic injury during colonoscopy is very rare but may result in significant hemorrhage. Proposed mechanisms of splenic injury include excessive traction/ torsion of the splenocolic ligament, direct trauma from navigation of splenic flexure leading to capsular avulsion, and protracted direct compression on spleen by colonoscope. Decreased motility of the spleen due to adhesions from prior surgery, previous pancreatitis, or inflammatory bowel disease and excess fragility because of splenomegaly due to hematological, infectious, and infiltrative diseases predispose to splenic injury during colonoscopy. Operatordependent risk factors for splenic injury include direct injury and excessive traction on the splenocolic ligament while navigating the splenic flexure. The common signs and symptoms of splenic injury are abdominal pain, left shoulder pain due to diaphragmatic irritation, peritoneal irritation, and hypotension.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Postpolypectomy syndrome (PPS) (also known as postpolypectomy electrocoagulation syndrome, and transmural burn syndrome) is a relatively uncommon complication and occurs in approximately 0.5–2.9% of patients undergoing polypectomy. Patients clinically present with localized pain, tenderness, fever, and leukocytosis without signs of generalized peritonitis and bowel perforation. The proposed mechanism of PPS is transmural burn injury to the colonic wall due to electrical current applied during polypectomy.CT plays an important role in diagnosing PPS and to exclude colonic perforation. CT findings of post-polypectomy syndrome include segmental concentric mural thickening with a stratified enhancement pattern and pericolonic inflammatory stranding without pneumoperitoneum. PPS is usually managed conservatively with fasting, intravenous hydration, and parenteral antibiotics; and thus CT helps in treatment planning by excluding perforation.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Although rare, other postcolonoscopy complications including acute appendicitis, diverticulitis, acute pancreatitis, liver abscess, chemical colitis, pneumothorax, pneumomediastinum, subcutaneous emphysema, intussusception, ureteral obstruction, and omental infarction have been seen. Acute appendicitis is an uncommon complication of colonoscopy and is thought to be due to forcing bowel contents into the appendix from insufflation and manipulation. Acute diverticulitis is rare complication of colonoscopy with incidence up to 0.029% as found in a large retrospective analysis done by Gorgun et al.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu · Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Complications after optical colonoscopy that can be identified on CT include bowel perforation (both macro- and microperforation), postprocedural hemorrhage, postpolypectomy syndrome, appendicitis, and diverticulitis. Given that optical colonoscopy is a common procedure, radiologist awareness of the potential colonoscopy complications seen at CT is imperative for appropriate diagnosis and subsequent patient management.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “Bowel perforation may occur relatively rarely from optical colonoscopy, occurring in ≤ 0.3% of screening colonoscopies up to 0.03–0.8% for diagnostic colonoscopy and 0.15–3% for therapeutic colonoscopy. At least three major mechanisms have been suggested: direct trauma from diagnostic colonoscopy, barotrauma from over insufflation, and perforation from therapeutic intervention.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “At CT, patients with macroperforation after optical colonoscopy may have a large amount of free gas. Extraluminal contrast material from oral or rectal administration may also be seen, if administered, potentially directly extravasating from the site of bowel perforation. When there is concern for perforation, any enteric contrast material given should be iodinated and water-soluble . If the surgical team requests rectal contrast material administration, it should be given carefully, preferably via Foley catheter. Many institutions, including ours, have eliminated the routine use of oral contrast material in the ED to avoid delay in imaging.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “Intraluminal hemorrhage is the most common major complication after optical colonoscopy. Although most patients do not undergo CT, their diagnosis and management is managed by the gastroenterologist (and other clinicians) . Postcolonoscopy hemorrhage hasbeen reported to occur in 1–6 of every 1000 colonoscopies. The rate is greater in patients who have undergone polypectomy (2.1– 3.7 per 1000 examinations, compared with 8.7 per 1000 examinations). Occasionally, a vascular lesion (i.e., hemangioma, arteriovenous malformation, or a prominent mucosal vein) may be biopsied with subsequentbleeding. Hemorrhage can occur immediately after the procedure or up to several weeks thereafter. Passage of a large amount of blood after optical colonoscopy is concerning for active hemorrhage. Delayed bleeding afterpolypectomy may be seen in 0.3–1.2% of patients who have undergone polypectomy and may occur 1–15 days after the procedure.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “Splenic injury from optical colonoscopy is a rare complication with an incidence of 0.0005–0.017% but with a mortality rate of 5%. A retrospective review of 296,248 colonoscopies by Kamath et al. found four cases of splenic injury (incidence of 0.001%). Only approximately 100 cases of splenic injury from optical colonoscopy have been reported in the literature to our knowledge.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “A retrospective review by Ha and Minchin, evaluating surgical findings in patients with splenic injury after colonoscopy (68.2% of who underwent preoperative CT), found subcapsular hematoma to be the most common finding (56.1%), followed bylaceration (47%) and rupture (33%). The frequency of these findings would presumably be similar on imaging. These complications are often accompanied by either small or large volume hemoperitoneum, depending on the severity of the splenic injury. CT findings in the multicenter review by Fishback et al. included subcapsular hematoma alone (45%), subcapsular and perisplenic hematoma (37%), laceration (27%), and splenic pseudoaneurysm .”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - “Postcolonoscopy complications that may be seen in patients in the ED include bowel perforation, postprocedural hemorrhage, postpolypectomy syndrome, splenic injury, appendicitis, and diverticulitis. CT is the imaging modality of choice in the ED, allowing rapid detection of these various complications. Although postcolonoscopy complications are infrequent, radiologist awareness of these complications and the associated imaging findings is essential for optimal diagnosis and prompt management.”
Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations
Robin B. Levenson, Katherine M. Troy, Karen S. Lee
AJR 2016; 207:W33–W40 - However, a colonoscopy is the most common cause of iatrogenic splenic injury (in comparison to other procedures or surgeries). The risk factors for splenic injury are both patient and operator dependent. Patient-dependent factors include pre-existing enlargement of the spleen, surgical adhesions, inflammatory bowel disease, and severe diverticular disease. Operator dependent factors include placing the patient on their back, excessive traction, over sedation, slide by advancement, and applying excessive external pressure. Despite these factors, it is still difficult to discern if the complication is unpredictable or directly related to technical factors given rarity of this complication.
- Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
Splenic injury after elective colonoscopy.
Sarhan M, Ramcharan A, Ponnapalli S.
JSLS. 2009;13(4):616-619.
- “Colonoscopy is one of the most commonly performed endoscopic procedures and remains the most commonly used screening modality method for colorectal cancer (CRC) screening in the USA. Although serious complications of fiberoptic colonoscopy are uncommon due to technical advances, due to increasing number of colonoscopy procedures, post-procedural complications are not uncommonly encountered in the routine clinical practice. Also, as some of the post-colonoscopy complications are life threatening, it is important to diagnose them early so that timely treatment measures can be taken to decrease mortality and morbidity. In this review, we present a case-based illustration of the utility of CT to detect complications of colonoscopy including bowel perforation, hemorrhage, splenic injury, and postpolypectomy syndrome.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “The most common complications of optical colonoscopy are hemorrhage and large bowel perforation. Less common complications include splenic injury, postpolypectomy syndrome, appendicitis, and acute diverticulitis. Unusual complications of colonoscopy include pneumothorax, omental infarction, liver abscess, septicemia, mesenteric tears, intussusception, and colonic volvulus. Also intraprocedural complications related to sedation and medications used during colonoscopy include vasovagal reactions (i.e., hypotension, bradycardia) and cardiovascular complications like arrhythmias and myocardial infarction.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Splenic injury during colonoscopy is very rare but may result in significant hemorrhage. Proposed mechanisms of splenic injury include excessive traction/ torsion of the splenocolic ligament, direct trauma from navigation of splenic flexure leading to capsular avulsion, and protracted direct compression on spleen by colonoscope. Decreased motility of the spleen due to adhesions from prior surgery, previous pancreatitis, or inflammatory bowel disease and excess fragility because of splenomegaly due to hematological, infectious, and infiltrative diseases predispose to splenic injury during colonoscopy.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Postpolypectomy syndrome (PPS) (also known as postpolypectomy electrocoagulation syndrome, and transmural burn syndrome) is a relatively uncommon complication and occurs in approximately 0.5–2.9% of patients undergoing polypectomy. Patients clinically present with localized pain, tenderness, fever, and leukocytosis without signs of generalized peritonitis and bowel perforation. The proposed mechanism of PPS is transmural burn injury to the colonic wall due to electrical current applied during polypectomy.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “CT plays an important role in diagnosing PPS and to exclude colonic perforation. CT findings of post-polypectomy syndrome include segmental concentric mural thickening with a stratified enhancement pattern and pericolonic inflammatory stranding without pneumoperitoneum. PPS is usually managed conservatively with fasting, intravenous hydration, and parenteral antibiotics; and thus CT helps in treatment planning by excluding perforation.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923 - “Intraluminal bleeding as a complication of optical colonoscopy typically occurs after a biopsy and polypectomy and is only rarely seen in the setting of a purely diagnostic examination. The incident of postpolypectomy bleeding ranges from 0.001–2%. Intraluminal bleeding can also result from inadvertent biopsy of a vascular lesion such as hemangioma, arteriovenous malformation, or a prominent mucosal vein associated with angiodysplasia.”
CT imaging findings of complications of optical colonoscopy
Abhishek Keraliya · Hei Shun Yu· Jennifer W. Uyeda
Emergency Radiology (2022) 29:915–923
- However, a colonoscopy is the most common cause of iatrogenic splenic injury (in comparison to other procedures or surgeries). The risk factors for splenic injury are both patient and operator dependent. Patient-dependent factors include pre-existing enlargement of the spleen, surgical adhesions, inflammatory bowel disease, and severe diverticular disease. Operator dependent factors include placing the patient on their back, excessive traction, over sedation, slide by advancement, and applying excessive external pressure. Despite these factors, it is still difficult to discern if the complication is unpredictable or directly related to technical factors given rarity of this complication.
- Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
Splenic injury after elective colonoscopy.
Sarhan M, Ramcharan A, Ponnapalli S.
JSLS. 2009;13(4):616-619. - Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy.
Splenic injury after elective colonoscopy.
Sarhan M, Ramcharan A, Ponnapalli S.
JSLS. 2009;13(4):616-619. - The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
Splenic injury after elective colonoscopy.
Sarhan M, Ramcharan A, Ponnapalli S.
JSLS. 2009;13(4):616-619.
- “Bowel and mesenteric injuries are detected in 5% of blunt abdominal trauma patients at laparotomy and are the third most common type of injury from blunt trauma to abdominal organs. Three basic mechanisms may cause bowel and mesenteric injuries of blunt trauma: Direct force may crush the gastrointestinal tract; rapid deceleration may produce shearing force between fixed and mobile portions of the tract; and a sudden increase in intraluminal pressure may result in bursting injuries.”
Evaluation of Bowel and Mesenteric Trauma with Multidetector CT
Brofman N et al.
RadioGraphics July 2008;26: 1119-1131 - “Computed tomography (CT) has been shown to be accurate for the diagnosis of bowel and mesenteric injuries and is the diagnostic test of choice in the evaluation of blunt abdominal trauma in hemodynamically stable patients. Specific CT findings of bowel and mesenteric injuries include bowel wall defect, intraperitoneal and mesenteric air, intraperitoneal extraluminal contrast material, extravasation of contrast material from mesenteric vessels, and evidence of bowel infarct.”
Evaluation of Bowel and Mesenteric Trauma with Multidetector CT
Brofman N et al.
RadioGraphics July 2008;26: 1119-1131 - “ The common sites of blunt trauma injury in the small bowel are the proximal jejunum, near the ligament of Treitz, and the distal ileum, near the ileocecal valve. In these regions, mobile and fixed portions of the gut are continuous and therefore are susceptible to shearing force.”
Evaluation of Bowel and Mesenteric Trauma with Multidetector CT
Brofman N et al.
RadioGraphics July 2008;26: 1119-1131