Transmural Colonic Infarction after Routine Colonoscopy in a Young Patient without Risk Factors

Abstract

Colonoscopy is one of the most widely used procedures in medical practice for the diagnosis and treatment of many benign and malignant diseases of the colorectal tract. Colonscopy has become the reference procedure for screening and surveillance of colorectal cancer. The overall rate of adverse events is estimated to be about 2.8 per 1,000 procedures, while complications requiring hospitalization are about 1.9 per 1,000 colonoscopies. Mortality from all causes and colonoscopy-specific mortality are estimated to be 0.07 and 0.007%, respectively. An exceptional fearsome postcolonoscopy complication is colon ischemia (CI); only few cases have been reported worldwide. We present the case of a 43-year-old woman who presented to the emergency department complaining of abdominal pain; fever and rectal bleeding appeared 12 h after a voluntary ‘screening’ colonoscopy. She had no risk factors for CI. Her laboratory tests showed alterations in inflammatory markers and a computed tomography scan showed a circumferential thickening in the left colon and free fluid in the abdomen. After 12 h of observation and conservative therapy, the clinical state of the patient worsened with the rising of signs of peritonitis. Laparoscopy showed that colon infarction extended from the distal third of the transverse colon to the proximal rectum. Laparotomy, resection of the pathological colon and terminal colostomy were performed. The specimen examined confirmed an extended ischemic colitis and transmural infarction on the antimesocolic side, in the absence of a vasculitis. The patient underwent recanalization after 8 months. CI after colonoscopy is a rare and alarming complication that must be known and taken into account in the differential diagnosis of symptomatic cases after colonoscopy, particularly in patients with known risk factors. The diagnosis is mainly based on clinical data, imaging and especially endoscopy. Treatment is almost always conservative but, in some cases in which the pathological process appears irreversible, surgery becomes mandatory.

Colonoscopy-related colonic ischemia

“…An extensive search of the literature showed 25 reports of colonoscopy-related colonic ischemia[ 22 ]. The first report in 1990 described a young woman with a history of systemic lupus erythematosus who developed abdominal pain and bloody diarrhea after a diagnostic colonoscopy.…”

“…These include the sudden onset of abdominal pain associated with nausea, vomiting, bloating, and passage of bright bloody diarrhea within 24 h, which often evolve in melena[ 8 ]. Zizzo et al [ 22 ] found that abdominal pain and bloody diarrhea were present in 95% of patients reported to have colonic ischemia after colonoscopy. Moreover, it is assumed that a non-negligible number of cases may be paucisymptomatic and thereby go undetected.…”

“…When signs of colonic ischemia are found, the endoscopic procedure should be halted at the most distal part of the affected segment[ 8 ]. In the existing reports of post-colonoscopy colonic ischemia, the diagnosis was confirmed with a second colonoscopy with biopsies in 85% of the cases[ 22 ]. Nevertheless, we believe that the indication to repeat colonoscopy must be weighed against clinical and radiological presentation in order not to worsen existing conditions.…”

“…In such cases, therapeutic options included general supportive measures, intravenous hydration, bowel rest, and correction of possible precipitating conditions including withdrawal of putative causative medications[ 36 ]. On the other hand, emergent surgery was needed in two cases of irreversible ischemia[ 22 ].…”

Ischemic Colitis after Colonoscopy with Bisacodyl Bowel Preparation: A Report of Two Cases

“…Additional identified risk factors include hypertension, cardiovascular disease, and diabetes mellitus [ 7 , 8 ]. Interestingly, colonoscopy itself has been described in the literature as a cause of IC with 25 studies identified globally [ 9 ]. In these case reports, we describe two cases of IC following colonoscopy with Bi-Peglyte (15 mg Bisacodyl/PEG 3350) used as bowel preparation.…”