Archives of Academic Emergency Medicine. 2020; 8(1): e84 CA S E RE P O RT Splenic Hematoma as a Rare Complication of Colonoscopy; a Case Report Maddalena Zippi1∗, Roberta Pica1, Ingrid Febbraro2, Francesco Rocco Pugliese3, Francesca Liguori3 1. Unit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy. 2. Unit of Urgent Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy. 3. Emergency Department, Sandro Pertini Hospital, Rome, Italy. Received: September 2020; Accepted: September 2020; Published online: 25 October 2020 Abstract: Splenic injuries after colonoscopy are an uncommon complication, which can lead to potentially unfortunate outcomes. Their management depends on the type of the splenic damage (hematomas, lacerations, rupture). We describe the case of a woman who visited the Emergency Department due to abdominal pain and pre- syncopal condition, which had occurred 12 hours after she underwent a colonoscopy. An abdominal computed tomography scan showed a splenic hematoma and a hemoperitoneum. An emergency splenectomy was per- formed successfully. Emergency physicians, who are at the forefront of diagnosing and treating patients, should consider this post-endoscopic complication in order to implement a prompt treatment. Keywords: Colonoscopy; computed tomography; hematoma; spleen; splenic rupture Cite this article as: Zippi M, Pica R, Febbraro I, Pugliese FR, Liguori F. Splenic Hematoma as a Rare Complication of Colonoscopy; a Case Report. Arch Acad Emerg Med. 2020; 8(1): e84. 1. Introduction Splenic rupture is a rare complication that may occur fol- lowing colonoscopy. The first description of this condition, due to an endoscopic procedure, dates back to 1974 (1). The main mechanisms involved are: tension of the splenocolic ligament and direct damage due to maneuvers of the colono- scope at the level of splenic flexure (2-4). The most likely predisposing causes are post-surgical adhesions, previous trauma, and underlying splenic pathology (2-4). Hereby, we describe a rare case of a splenic rupture that occurred after lower endoscopy. 2. Case presentation A 75-year-old woman was admitted to the Emergency De- partment due to abdominal pain associated to a pre- syncopal condition. Twelve hours earlier, she had performed a complete colonoscopy as a post-polypectomy surveil- lance at another hospital. The patient reported an open- ∗Corresponding Author: Maddalena Zippi; Unit of Gastroenterology and Di- gestive Endoscopy, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, 00157 Rome, Italy. Email: maddyzip@yahoo.it, Tel: +39-06-41433310, Fax: +39-06- 41733847 cholecystectomy, denied any kind of trauma in the previous days and mentioned that she was suffering from Hashimoto’s thyroiditis and arterial hypertension, for which she was reg- ularly in treatment with levothyroxine sodium and calcium channel blocker. No anticoagulant/antiplatelet agents were taken. On admission, the oral temperature was 38.6◦C, blood pressure 105/55 mmHg, pulse rate was 98/minute and the respiratory rate 17/minute. Increases in white blood cell count (16.4/mm3; neutrophils 85.1%) and plasma D-Dimer 359 (NR: 2-200 ng/ml) associated with anemia (hemoglobin 10.7 g/dl) were present. Renal, bilio-hepatic, and pan- creatic functions were normal. Physical examination re- vealed signs of peritoneal reaction to palpation. At this point, it was decided to perform an abdominal focused assessment with sonography (FAST), which demonstrated a hemoperitoneum. A subsequent computed tomography (CT) with intravenous (IV ) contrast highlighted, in addition to the hemoperitoneum (yellow arrows), the presence of a hematoma due to the rupture of the spleen (white arrow), as shown in Figure 1. Abdominal CT scan revealed the presence of a splenic hematoma of about 11 cm (withe arrows) and a copious intra-abdominal hemoperitoneum with perihepatic fluid collection (yellow arrows), in both arterial (figure 1a) and portal phases (figure 1b). A diagnosis of grade IV splenic rup- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Zippi et al. 2 Figure 1: Abdominal computed tomography with intravenous contrast. ture was made, according to the AAST (American Association for the Surgery of Trauma) classification (5). The patient un- derwent an emergency laparotomy with splenectomy, recov- ered well, and was discharged ten days later in good condi- tion. 3. Discussion In a 2016 review, Jehangir A et al. identified 172 cases of splenic rupture and noted an incidence of 1–21/100.000 for this complication, pointing out that it had a higher predom- inance among females (71.5% of cases), with a mean age of 63 years, and a previous history of abdominal surgery in 50.8–65% of cases (6). In a recent structured review, which included 45 articles for a total of 68 patients, Ullah W et al. emphasized two very interesting points regarding this complication: 1) the main reasons for performing the colonoscopy were screening in 46% of cases and diagnos- tic in 28%; 2) complete splenic rupture was found in 22% of patients, whereas subcapsular hematoma, spleen laceration and spleen avulsion were present in 63% of them (7). As evi- denced by the work of Chow BL et al., its real incidence could be underestimated both due to the non-reporting of cases and the non-publication of the same (8). Our patient, in ad- dition to abdominal pain, manifested a presyncopal condi- tion. In fact, hemodynamic instability was reported in 43.1% of patients known to be suffering from this disease (8). The diagnosis of a splenic rupture may be difficult, partly ow- ing to the delayed onset of the symptoms, even partly be- cause some physicians might not be aware of this rare com- plication. Early identification of this event is critical, as mor- tality rate is around 5% (9). As already affirmed above, we hold the view that Emergency doctors should take this en- doscopic complication into account to make an early diag- nosis and reduce the risk of mortality due to delayed treat- ment. Early recognition of this condition and the subsequent prompt treatment are essential to improve the outcome of these patients. 4. Conclusion Splenic rupture may be a dangerous complication of colonoscopy. FAST abdominal sonography performed in the emergency room certainly represents an excellent first di- agnostic examination in suspected cases. Nevertheless, ab- dominal CT scan represents the gold standard exam for de- tecting splenic rupture and splenectomy is required in most of cases. 5. Declarations 5.1. Acknowledgements The Authors thank Dr. Saveria de Vito, Italian Medicines Agency, Rome, Italy, for English editing. 5.2. Authors contribution (1) Each author listed had contributed to the conception or design of the paper, or to the acquisition, analysis, or inter- pretation of data. (2) Each author listed had participated in drafting the paper or revising it critically for important intel- lectual content. (3) Each author listed gave final approval of the version to be published. (4) Each author listed agreed to be accountable for all aspects of the paper, ensuring that questions related to the accuracy or integrity of any part are appropriately investigated and resolved. 5.3. Conflict of interest No conflict of interest was declared by the authors. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e84 5.4. Financial disclosure The authors declared that this study has received no financial support. References 1. Wherry D. Colonoscopy-fiberoptic endoscopic approach to the colon and polypectomy. Med Ann Dist Columbia. 1974;43:189-92. 2. Telmos A, Mittal V. Splenic rupture following colonoscopy. JAMA. 1977;237(25):2718-. 3. Patel DD, Shih DC, Terry SM. Splenic trauma from colonoscopy: A case series. International Journal of Surgery Case Reports. 2020;71:30-3. 4. Dziadkowiec KN, Stawinski PM, Radadiya D, Katz A. Left Shoulder Pain After Routine Colonoscopy: An Unusual Presentation of Splenic Laceration. Cureus. 2020;12(4):e7755. 5. Dziadkowiec KN, Stawinski PM, Radadiya D, Katz A. Left Shoulder Pain After Routine Colonoscopy: An Unusual Presentation of Splenic Laceration. Cureus. 2020;12(4):e7755. 6. Jehangir A, Poudel DR, Masand-Rai A, Donato A. A sys- tematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management. Inter- national Journal of Surgery. 2016;33:55-9. 7. Jehangir A, Poudel DR, Masand-Rai A, Donato A. A sys- tematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management. Inter- national Journal of Surgery. 2016;33:55-9. 8. Chow BL, Zia K. Postcolonoscopy splenic rupture: the under-reporting of an unpropitious phenomena? BMJ Case Reports CP. 2019;12(9):e231047. 9. Barbeiro S, Atalaia-Martins C, Marcos P, Nobre J, Gonçalves C, Aniceto C. Splenic rupture as a com- plication of colonoscopy. GE-Portuguese Journal of Gastroenterology. 2017;24(4):188-92. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References