Nursing Center - Journal Issue

Abstract

Complications associated with the performance of a colonoscopy are low. Splenic tearing or trauma postcolonoscopy is a rare but serious complication. Identification of a splenic injury is difficult because of the nonspecific nature of the patient's symptoms. A meta-analysis approach was used to identify common risk factors, onset and presentation of symptoms, and procedural difficulty associated with splenic injury postcolonoscopy. A review of 10 published case studies and 1 case presented by the author were compared with published findings for patients sustaining a splenic injury following colonoscopy. Potential common signs and symptoms as well as common risks factors were identified. Nursing considerations for the identification of high-risk patients and postprocedure symptoms are outlined. Early detection of this rare complication is difficult, but having a high level of suspicion can help to identify patients at risk for sustaining a splenic injury during colonoscopy.

The benefits of having a screening colonoscopy are well known by the gastroenterology community. Complications associated with the performance of a colonoscopy are low as compared with a patient's lifetime risk of being diagnosed with colorectal cancer. According to the Agency for Healthcare Research and Quality (2003), a person at age 50 years has about a 5% lifetime risk of being diagnosed with colorectal cancer and a 2.5% chance of dying from it; the average patient dying of colorectal cancer loses 13 years of life. The rate of reported serious complications associated with the performance of a colonoscopy varies from 0.34% to 2.5% (Ahmed, Eller, & Schiffman, 1997).

Splenic tearing or subscapular bleeding sustained during a colonoscopy procedure is a rare but serious complication. Diagnosis of a postcolonoscopy splenic injury is difficult because of the nonspecific nature of a patient's symptoms. A review of case studies may reveal common patient symptoms and presentation.

Background

Colonoscopy is the gold standard for screening and detection of colon cancer. Colorectal screening is recommended for all adults aged 50 and older. Statistics from the Centers for Disease Control and Prevention (2004) list colorectal cancer as the second leading cause of cancer death in the United States. It is estimated that an average of $9,000-$26,000 can be saved in individual healthcare costs annually if persons aged 50 years and older have a screening colonoscopy every 10 years (Agency for Healthcare Research and Quality, 2003).

The risk of a patient sustaining a splenic injury during colonoscopy appears to be low. The incidence of this rare, but serious, complication is not known in the United States. One publication reported the incidence of splenic injury as one case per 6,387 colonoscopies performed, for a calculated rate of 0.015% (Wu & Katon, 1993). The first case of splenic injury sustained during colonoscopy was published in 1974; since that time, a total of 66 cases of splenic injury after colonoscopy have been reported in the world literature (Saad & Rex, 2007).

A literature search using the key words "colonoscopy" and "splenic injury" revealed 10 case studies reported in peer-reviewed, English-only publications using the CINAHL and MEDLINE databases. A meta-analysis approach was used to identify common patient risk factors, symptoms, and presentation for splenic injuries postcolonoscopy. One case of splenic laceration with subscapular hematoma is reported by the author.

Case Study

A 65-year-old female patient presented to an ambulatory surgery center for a screening colonoscopy. The patient had a surgical history of appendectomy and hysterectomy. The patient's family history was negative for colonic malignancy or other chronic diseases. Her medical history was significant for hypertension, hypercholesterolemia, tendonitis, and bursitis.

The patient was placed in the left lateral position for the procedure. During the colonoscopy examination, the endoscopist experienced difficulty advancing the endoscope due to the tortuous nature of the patient's colon. The cecum was reached after employing multiple position changes and abdominal splinting. Initially, the assisting registered nurse applied splinting, using generally accepted methods for applying abdominal pressure. At one point during intubation of the colon, two nursing assistants were needed to apply abdominal pressure; the first assistant applied pressure directly to the patient's abdomen, whereas the second assistant provided counterpressure by bracing the patient's back. Procedure findings included an adenomatous descending colon polyp and a sigmoid polyp, both removed by hot snare polypectomy. The procedure course was uneventful with the exception of the difficulty reaching the cecum.

The patient experienced mild to moderate abdominal discomfort with nausea during the recovery period. After the patient expelled retained air, the abdominal discomfort and nausea improved prior to discharge. The patient rated her pain level as 1-2 of 10 (worse pain ever) at discharge.

Three days postprocedure, the patient called the gastroenterologist's office to report onset of left upper quadrant (LUQ) pain radiating to her left shoulder with nausea and vomiting. On follow-up the next day, the patient reported that her symptoms had improved but not completely resolved. Six days postcolonoscopy, the patient presented to the emergency room (ER) with shortness of breath and LUQ pain radiating to her left shoulder. A computed tomography (CT) of the thorax and abdomen revealed a collection of hyperdense fluid surrounding the spleen consistent with a splenic tear. The patient was admitted as an inpatient for observation of splenic tear and subscapular hematoma. Conservative management was employed by a general surgeon during the patient's 3-day hospital course. Serial hemograms remained stable and the patient's abdominal pain, left shoulder discomfort, and shortness of breath resolved prior to discharge.

A follow-up examination and repeated CT scan were performed 18 days postcolonoscopy. The CT scan showed organization of the hematoma and reduction of the hyperdense fluid. The patient continued to improve and returned to normal activity 27 days after the colonoscopy procedure.

Literature Review

A review of literature revealed three possible mechanisms of injury contributing to a patient sustaining a splenic injury during colonoscopy as follows: (1) formation of abdominal adhesions associated with a history of abdominal surgery, (2) increased splenocolic ligament traction associated with snare polypectomy and/or forceps biopsies performed during the colonoscopy, and (3) direct trauma to the spleen (Ahmed et al., 1997). Patients with a history of abdominal surgery empirically seem to present more technical difficulty in reaching the cecum, without using position changes or external abdominal pressure to assist the endoscopist in advancing the colonoscope. Abdominal adhesions may also increase the patient's risk of sustaining a splenic injury. It is unclear whether the presence of adhesions or the difficulty of advancing the scope is more of a factor in the incidence of splenic injury.

The splenocolic ligament is defined by Taber's Cyclopedic Medical Dictionary as a fold of peritoneum between the viscera of the spleen and colon. "Polypectomy and/or biopsy may predispose to splenic rupture due to the sudden excessive splenocolic ligament traction resulting from the procedure" (Prowda, Trevisan, & Lev-Toaff, 2005, p. 709). Direct trauma to the spleen can happen because of external pressure applied to the abdominal wall and/or internal pressure applied to the splenocolic ligament by the colonoscope. "Splenic trauma may result from hooking the colonoscope in the splenic flexure and pulling down on the splenocolic ligament hard enough to avulse the capsule" (Ahmed et al., 1997, p. 1202).

Factors that may increase a patient's risk of sustaining a splenic injury include splenomegaly, anticoagulation therapy, gender, and a history of multiple previous colonoscopies. This last factor may be related to increased traction on the splenocolic ligament. One researcher found that female patients had a 3:1 increased risk of splenic injury as compared with male patients, n = 63 (Saad & Rex, 2007). "The association of splenic trauma with female gender suggests an association with difficult colonoscopy, since colonoscopy is more likely to be difficult in women" (Saad & Rex, 2007, p. 894). Anatomic or other factors as the cause of the association with female patients cannot be ruled out as a contributing factor (Saad & Rex, 2007).

A review of published case studies was performed to identify common risk factors and signs and symptoms of splenic injury in postcolonoscopy patients. Ten published case studies were found by searching CINAHL and MEDLINE with the key words "colonoscopy" and "splenic injury." See Table 1 for a comparison of the 10 literature reviewed cases and the case presented by the author.

Table 1 - Click to enlarge in new window

TABLE 1. Comparison of Splenic Injury Cases

Case 10

A 73-year-old female patient with a surgical history of partial gastrectomy for bleeding ulcer, hysterectomy, and bladder repair underwent a colonoscopic examination for recent history of lower abdominal pain. The patient tolerated the colonoscopy procedure well and no procedural difficulty was reported. Her colon was normal, and after an uneventful recovery period, the patient was discharged 2 hours postprocedure. An hour after her arrival at home, the patient began experiencing left-lower and left-upper quadrant pain.

The pain worsened as the day progressed and began radiating to the left shoulder later in the evening. The patient presented to the emergency department and an acute abdominal series was performed, which showed no evidence of perforation. A CT scan demonstrated signs of a splenic laceration with free fluid around the spleen and within the pelvis. The patient was prescribed bed rest and blood transfusions for an acute drop in her hemoglobin level. One week postcolonoscopy, the patient was discharged in a stable condition (Boghossian & Carter, 2004).

Discussion

A meta-analysis of the case studies was undertaken to identify potential common risk factors, onset and presentation of symptoms, and procedural difficulty associated with splenic injury postcolonoscopy. Table 1 summarizes the onset and presentation of symptoms, procedure difficulty, presence of abdominal surgery history, and gender demographics for the collected case studies. The age of the patients included in this analysis ranged from 48 to 85 years. Age does not appear to be a relative risk factor for predicting if a patient sustains a splenic injury during colonoscopy.

Identification of a splenic injury is difficult because of the vague presentation of symptoms, but a high level of suspicion is a factor when diagnosing a splenic injury. Many patients experience abdominal bloating and discomfort postcolonoscopy due to insufflation of the bowel during the procedure. Patients experiencing significant abdominal pain not relieved by passing air should have bowel perforation ruled out as the cause of their abdominal pain, prior to workup for a splenic injury. Abdominal wall perforation is a known complication of colonoscopy. The risk of perforation during colonoscopy is estimated to be between 0.2% and 1% (Gupta & Reddy, 2006). It is recommended that hemodynamically stable patients have an acute abdominal series to rule out colon wall perforation before a CT scan of the abdomen is performed.

Risk Factors

Potential risk factors for splenic injury include the following:

1. Gender: 90% of cases reviewed involved female patients.

2. History of abdominal surgery: 55% of cases reviewed reported patients with a medical history of abdominal surgery.

3. Technical difficulty: 55% of case reports identified some type of technical difficulty during colonoscopy.

4. Gender appears to be a risk factor for splenic injury. A high level of suspicion is warranted for female patients on the basis of this analysis. A larger analysis of reported case studies found similar results, with 76% of cases involving female patients (n = 63) (Saad & Rex, 2007). A ratio of 2.8:1 and 3.2:1 (women:men) has been reported in two separate case study reviews published in peer-reviewed journals (Saad & Rex, 2007). All patients presenting with abdominal pain, where abdominal perforation has been ruled out, should be worked up for a possible splenic injury, no matter their gender, but a high degree of suspicion for female patients is warranted.

Patients presenting with a history of abdominal surgery also appear to have a higher incidence of splenic injury than patients without this history. The author's review found that 55% of cases had a history of abdominal surgery. A larger analysis of case studies reported that 65% (n = 37) of cases had a history of abdominal surgery prior to colonoscopy (Saad & Rex, 2007). A likely mechanism for splenic injury is related to formation of abdominal adhesions in patients with a medical history of abdominal surgery. The author's review and Saad and Rex's (2007) analysis support the findings that a history of abdominal surgery is a likely risk factor for splenic injury.

Although this review found that 55% of cases reported some type of technical difficulty during colonoscopy, the Saad and Rex (2007) review found that 36% (n = 45) of cases reported technical difficulty. Technical difficulty during colonoscopy appears to be a possible risk factor for splenic injury. Furthermore, analysis of case studies is needed to evaluate the correlation between technical difficulty and splenic injury.

Clinical Presentation

Most patients with a splenic injury reported onset of symptoms within 24-48 hours (Prowda et al., 2005). "The common signs and symptoms are abdominal pain without radiographic evidence of perforation, left shoulder pain (Kehr's sign), peritoneal irritation, and orthostatic changes" (Prowda et al., 2005, p. 710). Abdominal pain was reported in 100% of cases included in this review. Ninety-three percent of cases reviewed by Saad and Rex (2007) reported abdominal pain and 88% reported concurrent left shoulder pain in the presence of a splenic injury. Left-sided abdominal pain is the typical presentation reported by patients. Seventy-three percent of the cases reviewed by the author reported LUQ pain and 64% reported radiation to the left shoulder. Radiation of abdominal pain to the left shoulder, described as a positive Kehr's sign, appears to be a commonly associated symptom reported by patients. "Kehr's sign is pain referred to the left shoulder believed to be due to distention of the splenic capsule or irritation of the left diaphragm" (Saad & Rex, 2007, p. 895). Abdominal pain can be manifested because of multiple causes. The most common causes include retained air, abdominal bleeding, and colon wall perforation (Gupta & Reddy, 2006). Patients presenting with LUQ pain and a positive Kehr's sign should be evaluated for splenic injury after more common causes are ruled out.

The findings for patient onset of symptoms by the author do not appear to coincide with the larger analysis performed by Saad and Rex (2007). The review performed by Saad and Rex (2007) found that 14% (n = 56) of patients developed symptoms in the recovery room as compared with the author's findings of 46%. The author found that only 18% of cases reported onset of symptoms more than 5 hours postprocedure, whereas Saad and Rex (2007) found that 93% (n = 56) of cases reported onset of symptoms within 48 hours of the procedure, and of those, 79% developed symptoms after discharge from the endoscopy unit. Saad and Rex (2007) also report that only 7% (n = 56) of patients reported onset of symptoms 48 hours or longer postprocedure. The author concludes that the larger study performed by Saad and Rex (2007) reflects a more significant correlation between onset of symptoms and patients experiencing a splenic injury postcolonoscopy.

Nursing Considerations

Identification of a splenic injury postcolonoscopy is difficult because the incidence is rare. Identifying potential risk factors and contributing factors for the presumed mechanisms of injury can assist nurses in identifying high-risk patients. The following are recommendations compiled from the literature reviewed for this report and the analysis performed by the author.

Preprocedure

A preprocedure interview, nursing history, and physical examination should expose patients who have a high risk for adhesions between the spleen and colon (Ahmed et al., 1997). The Society of Gastroenterology Nurses and Associates (SGNA, 2003) recommends an age-specific patient assessment that includes previous medical, significant surgical, invasive procedure, and anesthetic history. A "review of the patient's symptoms and history will supply any pertinent information to be documented" (SGNA, 2003, p. 58). Potential risk factors that can be identified preprocedure (adapted from Ahmed et al., 1997; Prowda et al., 2005; Saad & Rex, 2007; Tse et al., 1999) include the following:

1. History of abdominal surgery.

2. Inflammatory bowel disease (IBD).

3. Splenomegaly and other diseases involving the spleen.

4. History of difficult colonoscopic and therapeutic procedures, including snare polypectomy and biopsies of the colon.

5. Anticoagulation therapy.

6. Pancreatitis.

A history of abdominal surgery, especially in female patients, appears to have a strong correlation as a potential risk factor for splenic injury. A high level of suspicion for these patients is recommended by the author. Inflammatory bowel disease and splenomegaly may increase a patient's risk for splenic injury, but to date, no strong correlation has been found. It seems logical that both IBD (IBD patients have a higher incidence of splenocolic adhesions) and splenomegaly would contribute to a patient's risk for splenic injury; therefore, documentation of this patient history or physical finding may be useful in assisting the gastroenterologist in identifying potential differential diagnoses for patients presenting with severe abdominal pain postcolonoscopy. A moderate correlation has been found between a history of multiple colon procedures, history of polypectomy and/or biopsy, and splenic injury incidence. Polypectomy and/or biopsy may increase a patient's risk for splenic injury due to excessive splenocolic ligament traction and adhesion formation (Ahmed et al., 1997). A history of multiple previous colonoscopies may be a risk factor for developing adhesions in the vicinity of the splenocolic ligament secondary to repeated episodes of traction (Prowda et al., 2005). Pancreatitis and anticoagulation therapy are listed as potential risk factors, but their correlation is not certain.

Intraprocedure

Technical difficulty during colonoscopy is a potential risk factor. Hooking of the colonoscope in the splenic flexure and downward force applied at the splenocolic ligament appears to lead to tearing or rupture of the splenic capsule (Ahmed et al., 1997). Technical difficulty can be decreased by applying external abdominal pressure; however, external abdominal pressure should be minimized to reduce the risk of splenic injury in high-risk patients (Ahmed et al., 1997). Published articles in the Society of Gastroenterology Nurses and Associates journal outline safe and effective application of abdominal pressure.

If technical difficulty is experienced during a colonoscopy, applying pressure to the patient's abdominal wall can help to prevent looping and minimize the angle of turns in the colon (Prechel, Young, Hucke, Young-Fadok, & Fleischer, 2005). It is recommended that abdominal pressure be applied slowly and deliberately to release the pressure slowly (Prechel et al., 2005). A forearm technique for applying abdominal pressure is described and illustrated by Prechel and Hucke (2009). Prechel and Hucke (2009) state that "using the forearm technique allows the assistant to provide effective and safe abdominal pressure, thereby reducing the risk of injury" (p. 30).

Multiple articles reviewed by the author recommend being aware of the amount of pressure being exerted on the abdomen. A direct measurement of the force exerted on the abdominal wall during application of abdominal pressure is difficult. One technique described by an ergonomics specialist involved using a Shampoeg Force Gauge to "mock up" applying abdominal pressure to patients in the left lateral and supine positions; five endoscopy nurses were interviewed and force measurements obtained (Enos, 2009). The average force exerted by the five nurses was 25-45 pounds of force (lbf) (Enos, 2009). A follow-up 3 months later revealed that the five nurses were able to reduce the force exerted (as measured by the Shampoeg device) to 10-16 lbf without affecting outcome (Enos, 2009). Advancement of the colonoscope through the colon and physician satisfaction was not affected by the reduction in force applied in a nonscientific study performed by the author. The ergonomics specialist recommended using a small weight scale to demonstrate what 15 lbf feels like, and trying to replicate that force when applying pressure to a patient's abdomen (Enos, 2009).

The standard technique for applying abdominal pressure used by the author was an open hand technique. An open hand technique is not recommended because of potential soft tissue injury to the assistant's wrists (Enos, 2009; Prechel & Hucke, 2009). The author has used the forearm technique with no appreciable difference in successfully reaching the cecum as compared with the open hand technique but has not found the forearm technique to be practical in all situations. Logically, a forearm technique should result in less force on the patient's abdomen by spreading the force over a larger surface area, but further research is needed to evaluate safe application of abdominal pressure.

Splenic trauma has been associated with the performance of a polypectomy and/or biopsy. In a review of 17 cases of splenic injury after colonoscopy, nine cases had more than one polypectomy and/or biopsy performed during the procedure (Ahmed et al., 1997). Documentation of therapeutic procedures and technical difficulty during colonoscopy can help to differentiate potential causes for postcolonoscopy abdominal pain. Continued analysis of published case studies can help to identify whether technical difficulty and polypectomy/biopsy are associated with a higher risk for splenic injury.

Postprocedure

The author's meta-analysis of reviewed cases for this article found 50% of patient's experiencing a splenic injury postcolonoscopy reported mild to moderate abdominal discomfort or no symptoms in the recovery room. The presentation of abdominal pain associated with splenic injury in the recovery room closely resembles abdominal cramping because of retained air. Patients typically improved prior to discharge. Therefore, identification of a splenic injury in a hemodynamically stable patient in the recovery room is difficult. As cited, the majority of patients have a progression of symptoms within 24-48 hours postcolonoscopy. Suspicion should be high in patients who develop persistent abdominal pain and acute anemia without evidence of intestinal perforation or bleeding (Ahmed et al., 1997). The following are signs and symptoms that may assist in identifying a patient with a splenic injury:

1. Left-sided abdominal pain, especially LUQ pain.

2. Radiation of pain to the left shoulder, Kehr's sign.

3. Persistent and progressive abdominal pain.

4. Onset of symptoms within 24-48 hours of the procedure.

5. Acute drop in hemoglobin/hematocrit.

6. Postural hypotension.

In the author's opinion, patient's complaining of persistent, worsening abdominal pain appears to be a common symptom of postcolonoscopy splenic injury. Triage nurses, nurse practitioners, endoscopy nurses performing follow-up phone calls, and other gastrointestinal healthcare professionals can assist the gastroenterologist in identifying patients who are at high risk for a splenic injury. "A high level of suspicion and close monitoring of high-risk patients should be able to detect splenic injury at an early stage" (Tse et al., 1999, p. 203).

Conclusion

A quality assurance investigation was performed on the author's case study. It was concluded after a literature review that the 65-year-old female patient was in a high-risk group. Specifically, the patient's gender and surgical history of hysterectomy and appendectomy were identified as risk factors. Technical difficulty as well as the removal of two polyps by snare polypectomy appeared to have increased the patient's risk for having a splenic tear. The association of force applied to the splenocolic ligament during the application of abdominal pressure and advancement of the colonoscope is unclear but appears to be associated with increased risk for splenic injury, in the authors' opinion.

The patient's course of treatment and outcome were appropriate with the exception of potentially ordering a hemogram when the patient called to report LUQ pain radiating to the left shoulder 3 days postprocedure. Given the patient's surgical history, gender, procedural findings, and the technical difficulty experienced, a high level of suspicion for splenic injury was indicated. Splenic injury after colonoscopy is rare, but identification of high-risk patients is possible. Having a high level of suspicion for splenic injury can assist in diagnosing this complication of colonoscopy early.