Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 12  |  Issue : 2  |  Page : 87-89
Non surgical management of the colonoscopic perforation: Report of a case


Department of Surgery, (Division of General Surgery) College of Medicine and King Khalid University Hospital, PO Box 7805, Riyadh 11472, Saudi Arabia

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Date of Submission16-Aug-2005
Date of Acceptance26-Dec-2005
 

How to cite this article:
Guraya SY, Al-Tuwaijri T, Noureldin O, Alzobydi AH. Non surgical management of the colonoscopic perforation: Report of a case. Saudi J Gastroenterol 2006;12:87-9

How to cite this URL:
Guraya SY, Al-Tuwaijri T, Noureldin O, Alzobydi AH. Non surgical management of the colonoscopic perforation: Report of a case. Saudi J Gastroenterol [serial online] 2006 [cited 2019 Nov 17];12:87-9. Available from: http://www.saudijgastro.com/text.asp?2006/12/2/87/27852


Since the introduction ofcolonoscopy in the late 1960s[1],the therapeutic and diagnosticapplications of colonoscopyhave grown dramatically with acomplication rate ranging from0.1 to 0.8 percent for perforation[2]and from 0.4 to 1 percent forhemorrhage[3]. The incidenceof colonic perforation duringcolonoscopy has been estimatedto be 0.04 to 0.9 per cent fordiagnostic colonoscopy, and 0.06to 0.7 per cent with therapeuticprocedures[4],[5]. The low mortalityrate of colonoscopic perforations(zero to 0.03 per cent)[6] maybe attributed to adequate bowelpreparation, early diagnosis andprompt traetment[7].

The management of colonicperforation secondary tocolonoscopy remains acontroversial subject in that itcan be effectively managed byoperative and non operativemeasures[8]. The choice between non operative and surgicaltreatment depends on the patient's general medical condition,the completeness of bowel preparation and the type ofcolonoscopic procedure performed[9]. Various authors haveadvocated a more conservative approach to perforationsresulting from therapeutic colonoscopy and an operativeintervention to the diagnostic-related perforations[10],[11]. Wepresent a patient who sustained a colonic perforation bytherapeutic colonoscopy and managed conservatively witha favorable outcome.


   Case report Top


We report a forty-year male, not known to have anymedical illness, with a history of rectal bleeding sincefour years. He used to pass altered colored blood, mixedwith stools although he denied tenesmus, weight loss orpainful defecation. Patient underwent colonoscopy whichrevealed a large polyp in the sigmoid colon which wassnared as a single mass with no immediate complication.The rest of colon appeared normal without the evidence ofhemorrhoids or any other local lesion which could explainedrectal bleeding. The patient was discharged home the sameday but developed abdominal pain and distension whichnecessitated hospital admission on the next morning. Onexamination, he was found to have tachycardia, temperature38 with generalized abdominal tenderness and absent bowelsounds. WBC count showed leukocytosis of 18000/mm3.Erect chest X-ray demonstrated pneumoperitoneum [Figure1] and gastrograffin enema outlined an area of contrastleakage from the sigmoid colon [Figure - 2]. CT scan of theabdomen and pelvis with oral and rectal contrast confirmedextravasation of the contrast from sigmoid colon with asmall collection measuring 10X10mm around that site[Figure - 3]. The patient was started on intravenous fluids,intravenous Cefuroxime 750mg and Metronidazole 500 mg8 hourly and bowel rest under strict bed side observationfor the vital and abdominal signs and daily WBC count. Hemade uneventful recovery and within 48 hours abdominalpain and distension and fever settled. The patient wasgiven intravenous Cefuroxime for five days and toleratedoral feeds very well. He was discharged home in a stablecondition. The histologic report of the subjected specimenshowed a 4X2.7X2.4 cm submucosal lipoma made up oflobules of mature adipocytes.


   Discussion Top


During the last thirty years, colonoscopy gained wideacceptance as an invasive procedure with low complications(0.1 to I percent)[7]. The frequency of complications,especially perforations, decline with experience but arenot always avoidable[12]. Perforation from diagnosticcolonoscopy requires surgical intervention morefrequently than that from therapeutic colonoscopy[10],[13].This observation stems from the fact that perforationsresulting from therapeutic and diagnostic colonoscopiesoriginate by different mechanisms. Perforations duringdiagnostic colonoscopy result from mechanical forcesduring insertion or from barotrauma, forcible instrumentinsertion, endoscopic torquing with alpha maneuver and the"slide-by" technique in which the colonoscope is advancedalong the mucosal surface without direct visualization[14].These manipulations cause undue stretching on thebowel with resultant linear tears of the mucosa on theantimesenteric side of the colon which can transmuralrupture[15]. Diverculosis enhances the risk of direct injuryby the colonoscope tip because of the danger in mistakingthe mouth of a diverticulum for the bowel lumen. Themost frequent site of mechanically induced perforation isthe intraperitoneal sigmoid colon because of its frequentredundancy, narrowing from diverticular disease andadhesions from previous pelvic operations.

Perforations after therapeutic procedures are more frequent.The mechanisms include the direct injury caused by biopsyforceps, brushes, dilators and more commonly the thermalor electrical injury when using laser or electrocautery. Theextent of tissue injury is related to the intensity of occurrenceand the duration of current application[16]. Perforationsfrom colonoscopy may be identified by the endoscopistduring the procedure or may have delayed presentation.Immediate perforation may be noticed visually by theappearance of mesenteric vessels, fat, or other bowel loopsthrough the clonoscope8. Delayed symptoms and signsof colonic perforation have been documented to occur upto 72 hours postprocedure[17]. Persistent abdominal pain,distension and tenderness with fever, tachycardia, absentbowel sounds and subcutaneous emphysema indicatecolonic perforation. Plain X ray of the chest and abdomenoften reveal pneumoperitoneum but lack of this findingdoes not exclude peritonitis[18]. Other radiological findingssuggestive of colonoscopic colon perforation includepneumomediastinum, pneumopericardium, pneumothoraxand pneumatosis intestinitis[19],[20],[21],[22]. CT scan and watersoluble contrast enema are helpful in establishing the sizeand extent of injury with more precision.

Several large studies have reported that many patientswith colonic perforations may be successfully treatedwithout surgery[23],[24]. Non operative treatment involveshospitalization, intestinal rest and intravenous fluidsand antibiotics to contain peritonitis and allow theperforation to seal[25]. Close observation is mandatory andsurgical intervention should be sought patients' conditiondeteriorates or there is no improvement in 72 hours. Onthe other hand, operative treatment is indicated for patientswith diffuse peritonitis, failure of medical treatment,large colonic injuries, ongoing sepsis and those withunderlying pathology (i.e. cancer, unremitting colitis anddistal obstruction)[9]. The surgical procedures range fromprimary repair, resection and anastomosis or defunctioningcolostomy. A stoma may be more appropriate withsignificant peritoneal soilage, hemodynamic instability andcomorbidities[23]. Colonic lipomas are rare with a reportedautopsy incidence of 0.2% [26]. Although the majority ofthese lesions manifest with vague abdominal pain, largepeduncutated lipomas may present with intermittentcolonic intussusception[27],[28].

To conclude a significant number of patients withcolonoscopic perforations can be treated non operativelybut a successful outcome must be achieved rapidly. Medicalmanagement in the surgical setting is safe and reliable butdemands meticulous monitoring and timely judgment.

 
   References Top

1.Wolf WI, Shinya H. Colonofiberoscopy. JAMA 1971; 217: 1509-12  Back to cited text no. 1    
2.Kavin H, Sinicrope F, Esker AH. Manegement of perforation of the colon at colonoscopy. Am J Gastroenterol 1992; 87: 161-7  Back to cited text no. 2  [PUBMED]  
3.Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-83  Back to cited text no. 3  [PUBMED]  
4.Christie JP, Marrazzo J. "Mini-perforation" of the colon: not all post polypectomy perforations require laparotomy. Dis Colon Rectum 1991; 34: 132-5  Back to cited text no. 4    
5.Nivatvongs S. Complications in colonoscopic polypectomy: an experience with 1555 polypectomies. Dis Colon Rectum 1986; 29: 825-30  Back to cited text no. 5  [PUBMED]  
6.Farley DR, Bannon MP, Zeitlow SP. Management of colonoscopic perforations. Mayo Clin Proc 1997; 72: 729-33  Back to cited text no. 6    
7.Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy and flexible sigmoidoscopy. Gastrointest Endosc Clin North Am 1996; 6: 343-77  Back to cited text no. 7  [PUBMED]  
8.Damore LJ, Rantis PC, Vernava AM, Longo WE. Colonoscopin perforations. Dis Colon Rectum 1996; 39(11): 1308-1314  Back to cited text no. 8    
9.Cobb WS, Heniford BT, Sigmon LB, Hasan R. Colonoscopic perforations: incidence, management and outcomes. The Am Surg 2004; 70(9): 750-9  Back to cited text no. 9    
10.Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg 1994; 179: 333-7  Back to cited text no. 10  [PUBMED]  
11.Adair HM, Hishon S. The management of colonoscopic and sigmoidoscopic perforations of the large bowel. Br J Surg 1981; 68: 415-6  Back to cited text no. 11  [PUBMED]  
12.Heath B, Rogers A, Taylor A, Lavergne J. Splenic rupture: an unusual complication of colonoscopy. Am J Gastroenterol 1994; 89: 449-50  Back to cited text no. 12  [PUBMED]  
13.Ker TS, Wasserberg N, Beart Jr RW. Colonoscopic perforation and bleeding of the colon can be treated safely without surgery. The Am Surg 2004; 70 (10): 922-4  Back to cited text no. 13    
14.Blumberg D, Beck DE. Colonoscopic perforations. Perspect Colon Rectal Surg 2000; 12: 77-89  Back to cited text no. 14    
15.Williams C, Teague R. Colonoscopy. Gut 1973; 14: 990-1003  Back to cited text no. 15  [PUBMED]  
16.Tedesco FJ. Colonoscopic polypectomy. In: Silvis SE, ed. Therapeutic Gastrointestinal Endoscopy. New York: Igaku-Shoin, 1985: 269-288  Back to cited text no. 16    
17.Hall C, Dorricott NJ, Donovan IA, Neoptolomos JP. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991; 78: 542-4  Back to cited text no. 17    
18.Winek TG, Mosley S, Grout G, Luallin D. Pneumoperitoneum and its association with ruptured abdominal viscus. Arch Surg 1988; 123: 709-12  Back to cited text no. 18    
19.Fitzgerald SD, Denk A, Flynn M, Longo WE, Veranave AM. Pneumoperitoneum and subcutaneous emphysema of the neck: an unusual manifestation of colonoscopic perforation. Surg Endosc 1992; 6: 141-3  Back to cited text no. 19    
20.Meyers MA, Ghahremani GL. Complications of fiberoptic endoscopy. Radiology 1975; 115: 301-7  Back to cited text no. 20    
21.McCollister DL, Hammerma HJ. Air, air, everywhere: pneumatosis cystoceles coli after colonoscopy. Gastrointest Endosc 1990; 36: 75-6  Back to cited text no. 21    
22.Thomas JH, Pierce GE, MacArthur RI. Bilateral pneumathoraces secondary to colin endoscopy. J Natl Med Assoc 1979; 71: 701-2  Back to cited text no. 22  [PUBMED]  
23.Opelka FG. Transmural endoscopy. In; Hicks TC, Beck DE, Opelka FG, Timmcke AE, eds. Complications of colon and rectal surgery. Baltimore: Williams and Wilkins, 1996: 143-52  Back to cited text no. 23    
24.Nivatvongs S. Complication in colonoscopic polypectomy: lessons to learn from an experience of 1576 polyps. Am Surg 1988; 54: 61-3  Back to cited text no. 24  [PUBMED]  
25.Araghizadeh FY, Timmcke AE, Opelka FG, Hichs TC, Beck DE. Colonoscopic perforations. Dis Colon Rectum 2001; 44(5): 713-6  Back to cited text no. 25    
26.Ho KJ, shin MS, Tishler JM, Computed tomographic distinction of submucosal lipoma and adenomatous polyp of the colon, Gastrointest Radiol 1984; 9:77-80.  Back to cited text no. 26    
27.Chan KC, Lin NH, Lein HC, Chan SL. Yu SC. Intermittent intussusception caused by colonic lipoma. J Formos Med Assoc 1998, 97 63-5.  Back to cited text no. 27    
28.Abdulkarim AA. Endoscopic management of a large sigmoid lipoma with intussusception in a young woman: case report. Saudi J Gastroentrol 2001; 7: 34-6.  Back to cited text no. 28    

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Correspondence Address:
Salman Y Guraya
King Khalid University Hospital, PO Box 286896, Riyadh 11323
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.27852

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[Figure - 1], [Figure - 2], [Figure - 3]



 

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