Splenic rupture after colonoscopy.

A (Not So) Rare Complication of Colonoscopy

Since its first report in 1974, 66 cases of splenic injury after colonoscopy have been reported in the world literature. Splenic injury is among the rarest complications of colonoscopy. However, it can be associated with severe morbidity and has rarely been fatal. Three cases of splenic injury following colonoscopy are described, and the world literature is reviewed. Case reports and literature review. Seventy-six percent of the patients were females. When reported, colonoscope insertion was technically difficult in 36% of cases. The onset of symptoms is usually within 48 h of colonoscopy. Abdominal pain was the most common presenting symptom (93% of cases). CT scan and ultrasound each had 100% diagnostic sensitivity when performed. Twenty of 65 cases (31%) with available data were successfully managed supportively with bed rest, transfusion and pain control. Hemodynamic instability was associated with surgical treatment, but no clinical features were perfect predictors of successful conservative therapy or the need for surgery. Splenic injury during and after colonoscopy is more common in women. Technically difficult colonoscopy is a possible risk factor. Onset of symptoms is often delayed by hours. CT scan is probably the best diagnostic test for splenic injury after colonoscopy, though the literature indicated ultrasound is also sensitive. Patients with hemodynamic instability are most often operated. Patients with confined intrasplenic hematoma and hemodynamic stability can be given a trial of conservative management.

Splenic rupture is an uncommon complication of colonoscopy. A high index of suspicion is a crucial factor in the prompt diagnosis of this rare but potentially fatal complication. We report a case of splenic rupture diagnosed 3 days after a colonoscopy and requiring splenectomy. We also reviewed 17 reported cases of splenic rupture after colonoscopy, including our case. The presumed mechanisms of splenic rupture during colonoscopy are direct trauma to the spleen, excessive splenocolic ligament traction, and decrease in the relative mobility between the spleen and the colon. Of the 17 cases reviewed, 10 had polypectomy and/or biopsy performed during colonoscopy. Other probable risk factors are identified and tabulated. The hemodynamic status of the patient is the primary factor used to determine the therapeutic option. Computed tomographic (CT) scan of the abdomen reliably demonstrates well-contained splenic laceration and subcapsular hematoma, and differentiates these splenic complications from perisplenic clot and hemoperitoneum. Thus, CT scan may help decide which patients may be managed operatively or nonoperatively. Splenectomy is the operative procedure of choice for splenic rupture after colonoscopy. Conservative management includes broad spectrum antibiotics, intravenous fluids, blood transfusion, and close hemodynamic monitoring. The factors mandating further evaluation of persistent abdominal pain after colonoscopy are hemodynamic instability, clinical features of acute abdomen, leukocytosis, and/or acute anemia. The onset of abdominal pain associated with one or more of these critical factors is usually within 24 h after colonoscopy. An emergent CT scan of the abdomen is the modality of choice to further evaluate these clinical features, but intestinal perforation and external bleeding must first be excluded.

293 Return Rates for Opioid Versus Non-Opioid Management of Abdominal Pain in the Emergency Department

Acute abdominal pain is one of the most common reasons for emergency admissions. Even though initial differentials are wide, a physician is able to narrow them down with detailed history, careful physical examination, and appropriate laboratory tests along with imaging studies. Unfortunately, some of the cases do not have an established diagnosis despite multiple blood work and imaging studies in the emergency department. In such conditions, physicians' recognition of rare diseases generally avoids extra costs for additional investigations, unnecessary consultations, and most importantly wasting valuable time in life-threatening conditions in emergency settings.Here, we report a 30-year-old woman with acute severe abdominal pain and hemodynamic instability who was found to have ascites that was actually hemoperitoneum secondary to spontaneous primary non-parasitic splenic cyst rupture. The primary splenic cyst is an extremely rare entity and is often found on imaging incidentally. A few case reports regarding primary splenic cyst and its complications were published in the literature. Since it is an exceptionally uncommon condition, there is no consensus on treatment. We aimed to increase the understanding of spontaneous primary splenic cyst rupture and its management among healthcare providers with this case report.

Background: Tumors in the transverse colon that invade adjacent organs, such as the ileum and posterior stomach, present complex surgical challenges. Resection and reconstruction are often required to achieve optimal outcomes. We present a case of a large transverse colon tumor adherent to the ileum and posterior gastric wall, managed with extensive surgical resection and reconstruction. Case: A 54-year-old male presented with abdominal pain, bloating, and weight loss. Imaging studies revealed a large mass originating from the transverse colon, adherent to the ileum and posterior gastric wall. Intraoperative findings confirmed the tumor’s adherence to the ileum, approximately 220 cm distal to the ligament of Treitz, as well as its invasion of the posterior gastric wall. The surgical team performed a multi-organ resection. The segment of ileum involved, located 220 cm from the ligament of Treitz, was resected, and an ileo-ileal anastomosis was performed. The primary tumor, located in the middle of the transverse colon, necessitated a total resection of the transverse colon, with subsequent anastomosis between the ascending and descending colon. Additionally, the portion of the posterior stomach adherent to the tumor was removed through subtotal gastrectomy, followed by a Billroth I reconstruction. Postoperatively, the patient recovered well, with no significant complications. Histopathology confirmed the tumor to be a moderately differentiated adenocarcinoma. The patient is currently undergoing adjuvant chemotherapy. Conclusion: This case highlights the complexity of managing tumors with multi-organ involvement. Comprehensive surgical resection, combined with appropriate reconstruction techniques, can result in favorable outcomes. Early detection and aggressive surgical management are essential in cases involving locally advanced tumors with invasion into adjacent structures.

BackgroundGastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma.Case presentationA 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma.ConclusionA gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

Splenic injury after colonoscopy is a rare (1:100 000) but serious complication after colonoscopy associated with high morbidity. Consequences range from a mild, self-limited splenic haematoma to the catastrophic shattered...

A 42-year-old woman presented with abdominal pain. On the basis of CT results, we diagnosed her condition as bowel obstruction caused by advanced transverse colon cancer. Colonoscopy findings showed three lesions: (i) an advanced tumor in the transverse colon; (ii) a laterally spreading descending colon tumor; and (iii) a rectal polyp. The tumors and the polyp were all pathologically diagnosed as adenocarcinoma. After inserting a self-expanding metallic stent into the main tumor of the transverse colon to decompress the bowel, we performed endoscopic submucosal dissection of the laterally spreading descending colon tumor. Pathological examination results showed submucosal invasion and a positive margin. Because we endoscopically identified that the rectal polyp was invading the submucosa, we performed laparoscopic subtotal proctocolectomy and ileorectal anastomosis with lymph node dissection along the surgical trunk; we also performed central vascular ligation of the ileocolic artery, right and left branches of the middle colic artery, and inferior mesenteric artery. The patient's postoperative course was uneventful. We present this case because there have been few reports on laparoscopic subtotal or total proctocolectomy for synchronous multiple colorectal cancers.

Purpose: A 53 year old veteran underwent colonoscopy to evaluate a positive fecal occult blood test. The endoscopy revealed eight dimunitive polyps in the transverse, descending, and sigmoid colon, excised by cold biopsy, and two one centimeter sigmoid polyps removed by snare cautery. The procedure was uneventful and the patient felt well the remainder of the day. The following morning, he was awoken by severe left sided abdominal pain and developed vomiting. He presented to the ED with worsening of his symptoms and was found to have a WBC of 15.9 and HgB of 8.5 (down from 13.8) with systolic blood pressures in the 70s. He had left sided abdominal pain at this time with no rigidity or rebound and normal bowel sounds. He denied any rectal bleeding or melena and a fecal occult blood test was negative. A KUB revealed no free air. The patient's abdominal exam evolved to include right upper quadrant and periumbilical pain but still without rigidity or rebound. He was given four units of PRBCs and 4 L of normal saline and his systolic pressures remained in the 70s. CT scan revealed a 21 × 14 × 14 cm hematoma around the spleen, consistent with splenic rupture. The patient was rushed to the operating room for emergent exploratory laparotomy and splenectomy. Post-operatively, he had an uneventful recovery and was discharged on day 5. Diagnostic colonoscopy is well tolerated by patients and has a complication rate of 0.02% to 1.8%. Splenic rupture after colonoscopy is a rare yet important complication with over fifty reported published cases. The true incidence remains unknown. As with our patient, most cases have presented within twenty-four hours of endoscopy, are associated with no particular endoscopic difficulty, and are diagnosed by CT scan. Though some published cases have been managed medically, the majority as in this case have required operative intervention with most patients making a full recovery.

BackgroundSplenic artery aneurysms are rare and usually asymptomatic, with a high risk of mortality once they get ruptured. This is a rare case of a spontaneous splenic artery aneurysm rupture in a high-risk patient for surgery. Endovascular treatment was the only option to save patient’s life.Case presentationWe report a 70-year-old woman with multiple comorbidities, presenting to the emergency department with signs of shock: confusion, pallor, tachycardia, and hypotension. Computed tomography shows an active bleeding from a splenic artery aneurysm rupture. The patient was successfully submitted to emergent arterial embolization of the splenic artery aneurysm.ConclusionsEndovascular treatment is a less aggressive approach and should be considered in high-risk patients for surgical intervention. Rupture of a splenic aneurysm is a rare condition with high mortality rate and should be considered as a differential diagnosis in a patient with abdominal pain and hemodynamic instability.

The Hypoganglinosis is a rare and resembles Hirschsprung’s disease in the male-to-female ratio, etiology and clinical presentation. Although chronic constipation is a common complaint in general population, the patients with constipation can accompany with fatal complication if the patient with megacolon which is related with hypoganglinosis. Up to 90.5% of patients with Hirschsprung’s disease are diagnosed in the newborn period and the median age at diagnosis of the patient with hypoganglinosis was 4.85 years old. We report a healthy 43 year-old male with severe constipation who is diagnosed as adult type hypoganglinosis. A 43-year-old man presented with chronic constipation, abdominal discomfort, and flatulence, and had been passing intestinal gas with unusual odors for 18 months. Computed tomography showed a severely dilated feces-filled proximal segment of the descending colon and transverse colon. The patient underwent subtotal colectomy with ileocolic anastomosis for a clinical impression of intractable megacolon. Histopathology confirmed a diagnosis of hypoganglionosis of the colon. The hypoganglinosis is rare disease in population, especially in adult group. However, the early and accurate diagnosis of adult hypoganglionosis is important for the physician to avoid fatal complication. We hope that adult intestinal innervation disorders will be considered readily in the differential diagnoses of chronic constipation.

Emergency surgery for complicated colorectal cancer in central Brazil

77 Results of a Novel National Emergency Department Chief Complaint Database

A 72-year-old female was admitted to the hospital because of upper abdominal pain and vomiting. A chest plain film demonstrated dextrocardia and bowel gas at the left phrenic o-costal angle. An upper GI barium series and barium enema revealed that the antrum portion of the stomach and transverse colon were incarcerated in the left thoracic cavity. Surgery was carried out using the trans abdominal approach. The operative findings included that the hernia sac contained the greater omentun, stomach and transverse colon; and that the liver and gallbladder were found in the left side of the abdominal cavity, the spleen was in the right side of it. Moregagni hernia has been reported in around 3% of all diaphrag-matic hernias, but we could not find any literature concerning this disease associated with situs inversus. The most valuable diagnostic approaches were chest X-ray, CT, or MRI scan and barium GI series. She was discharged in satisfactory condition on the 14th postoperative day uneventfully.