After approximately two decades in the field of GI endoscopy, I felt relatively secure in the knowledge I had gained regarding complications associated with routine colonoscopy. Most endoscopy nurses and assistants are familiar with the most common of these, including perforation, hemorrhage, post-polypectomy syndrome, and sedation-related incidents. While it’s true that polypectomy increases the risk, colonoscopy overall is considered a safe procedure with a complication rate of less than .35 percent.
Needless to say, I was alarmed upon receiving a call from an affiliate endoscopy center earlier this year informing me of the death of a patient who had undergone an elective routine colonoscopy. Apparently, this healthy 69-year-old woman had complained of shoulder pain upon retiring that evening and was found dead in bed by her husband the following morning. The cause of death was determined to be a ruptured spleen.
In spite of an overwhelming sense of horror, I didn’t give much further thought to this nightmare scenario until I was vacationing in my home in Florida some months later.
There was some talk in the community that one of our neighbors had been hospitalized and was quite ill after undergoing a colonoscopy. As it turned out, she remained an inpatient for five days while receiving conservative treatment for injury to her spleen. The procedure itself was uneventful and it was not until the following day that she presented with abdominal pain radiating to her shoulder.
Although I had now heard of two such cases involving the spleen in just six short months, I was convinced that this was no more than a coincidence. I was certain that this was not a common complication associated with colonoscopy and, in fact, I could not even recall ever reading or hearing about this in all of my years in endoscopy. What was about to happen next finally motivated me to look into this phenomenon and to share the information that I gleaned.
Approximately three weeks ago, I came into the office on a Monday morning to find that a 53-year-old woman, who had undergone a screening colonoscopy with us the Friday before, had presented to the emergency room over the weekend with complaints of abdominal pain and weakness. After diagnostic testing, it was determined that she had sustained a tear to her spleen and within three hours underwent an emergency splenectomy. This colonoscopy had also been uneventful with no difficulties or delay in reaching the cecum and no need for biopsy or polypectomy.
Although it was true that I had never before heard of splenic rupture mentioned in the same sentence as colonoscopy, this had changed precipitously over the previous nine months. I turned to the literature to see what I could find out about this complication. Splenic trauma related to colonoscopy is considered to be exceedingly rare with less than 50 cases reported—the first appearing in 1974. Some authors theorize that the incidence may be significantly higher as some endoscopists may be less inclined to report such cases due to a high level of morbidity in these patients.
Although splenic rupture or injury can occur in both anatomically normal and abnormal spleens, there are some purported predisposing factors that may increase the risk. These include a history of abdominal surgeries or trauma, splenomegaly (whether from infiltrative diseases, infections, or hematological origins), pancreatitis, inflammatory bowel disease and the use of anticoagulants. While a definitive etiology has yet to be determined, the common thread associated with most of the above risk factors is splenocolic ligament adhesions. Such adhesions may alter the mobility of this ligament resulting in excessive traction, pulling, and tearing, particularly as the endoscopist attempts to negotiate the splenic flexure.
Splenic injury has also been suspected to result from certain colonscopic techniques such as hooking the splenic flexure to straighten the descending colon, the slide-by technique, the alpha maneuver, and straightening of the sigmoid loop. These maneuvers, though practiced often as a necessity in performing successful colonoscopy, may increase traction on the splenocolic ligament. In cases where any of the above pre-existing risk factors exist, such maneuvers may be more likely to lead to injury.
The articles that I had read in my quest to understand more about this complication were quite illuminating although not very reassuring. I had hoped at the outset that I would be unable to confirm a sneaking suspicion that abdominal pressure applied by the endoscopy assistant (and yes, that sometimes includes me) might be mentioned as part of the culprit. Much to my dismay, this technique has actually been proposed as another possible risk factor for splenic rupture either through direct trauma to an enlarged spleen or simply by decreasing the mobility between the colon and the spleen.
Specific reference was also made to the application of pressure to the left upper quadrant when the patient is in the supine position. Supposedly, the gravitational pull on the spleen and the traction imposed by the colonoscope would be in direct opposition to one another which could lead to even greater traction on the splenocolic ligament. There was no mention in what I had read, however, about the amount of pressure applied by the assistant. This led me to wonder whether any measure of pressure applied to any part of the abdomen could be implicated as contributing to such a complication during colonoscopy. One author even suggested that external abdominal pressure be avoided altogether during this procedure.
Allow me to briefly digress while I opine my confusion and anxiety over the fact that I have never been taught specifically to avoid applying “too much” pressure (although I’m not a large person), never mind being advised to apply no pressure at all. I’ve seen some endoscopists apply the weight of their own body with their elbows, for heaven’s sake!
Haven’t we all learned, from day one in the endoscopy room, that there are times when the application of abdominal pressure is valuable and frequently necessary in facilitating successful completion of a colonoscopy? Mayo Clinic physicians unanimously agree that abdominal pressure is beneficial with 15 gastroenterologists and colorectal surgeons admitting in a survey to the use and effectiveness of this technique in almost all of the colonoscopies they perform.
A look through several articles and a DVD on the technique of applying abdominal pressure during colonoscopy (all specifically designed for the assistant) confirmed my recollection that the possibility of splenic injury was not mentioned nor was any appreciable reference made to the danger of pressing too firmly on the patient’s abdomen.
Most of the information provided involved the various hand positions and the direction of pressure that could be applied in order to attain the most optimum effect, i.e. advancement of the scope. Considerable attention was given to educating the reader about the use of proper body mechanics so that injury to the assistant would be averted. There was the occasional statement reminding the reader of patient safety and the use of common sense when applying pressure by taking into account the size and weight of the patient.
I scoured anything I had ever read on abdominal pressure to see if I had been remiss in noticing any bold-faced warnings that spelled out the need to avoid “pressing too firmly or suffer the consequence of a ruptured spleen.” One article that I had read on the subject and saved for future reference, even reminded the assistant that when applied correctly, with firm compression using the palm of the hand, abdominal pressure could allow for easier and less painful insertion of the colonoscope.
In the final analysis, I began to wonder whether abdominal pressure was implicated in reports of splenic rupture because the application of pressure was almost always used when intubation of the colon was particularly difficult. Perhaps it was this difficulty, and not the pressure, that was to blame as rupture of apparently normal spleens have been reported after technically challenging colonosopies. Regardless, it behooves all of us who are called upon to use abdominal pressure, or to merely assist in the care of patients undergoing colonoscopy, to be mindful of splenic rupture as a possible complication.
Knowledge regarding splenic rupture may help to assist in an early diagnosis, which is paramount due to the high morbidity and mortality associated with this injury. The patient usually presents with symptoms within a few hours of the colonoscopy, though late presentation can occur anywhere from 24 hours to 10 days later. The patient may experience clinical features of an acute abdomen such as diffuse abdominal pain (often referred to the left shoulder), distention and tenderness, as well as hemodynamic instability and acute anemia due to blood loss.
Intestinal perforation must initially be ruled out—keeping in mind that the X-ray traditionally used for this purpose will not be helpful in the diagnosis of splenic rupture. A CAT scan is the imaging modality of choice in the identification of the exact nature of the sustained injury. Free fluid, subphrenic or perisplenic hematoma, lacerations, hemoperitoneum (massive at times), or avulsion of the splenic capsule are some of the findings that may be revealed. Treatment is more likely to be surgical, with removal of the spleen, in those patients who present with hemodynamic instability and/or pre-existing splenic diseases.
Hemoperitoneum on CT scan, need for transfusion of greater than one unit, and injuries graded higher than three on the American Association of Surgery for Trauma and Splenic Injury Scale would also fall into this treatment category.
A more conservative approach—consisting of transfusion, intravenous fluids, broad-spectrum antibiotics, and cardiovascular monitoring—might be considered in stable closed subcapsular splenic hematomas and would be used more often in patients who are not very young or very elderly. In certain situations, splenic artery embolization has even been utilized in an attempt to stop bleeding without the need for surgery.
As nurses and assistants we must be cognizant of the possibility of splenic rupture as a complication of colonoscopy. Awareness of the predisposing factors that may increase the risk and an understanding of the warning signs that may provide a clue to early diagnosis, can help protect your patient against a disastrous outcome. Discussion of this phenomenon as it relates to the application of abdominal pressure and adoption of the safest approach to this technique are additional measures that can be taken toward this end. Although this is fortunately not a common occurrence, keep in mind that splenic rupture may not be as rare as we think.
Patricia DeSouza, RN, BS, CGRN, has managed endoscopy units in hospital- and office-based settings. During the past year she has worked as a consultant assisting 26 office-based endoscopy practices successfully achieve accreditation.
