Gastroenterology journal 2019156e12e13 A 73yearold woman underwent surveillance colonoscopy for a history of colon adenomas The colonoscopy was uncomplicated and remarkable for 3 small rectosigmoid ID: 909178
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Slide1
Small Bowel Necrosis After Colonoscopy
Gastroenterology journal 2019;156:e12–e13
Slide2A 73-year-old woman underwent surveillance colonoscopy for a history of colon adenomas.
The colonoscopy was uncomplicated and remarkable for 3 small
rectosigmoid
polyps that were
resected
with cold biopsy forceps.
Slide3The patient was discharged home, and approximately 12 hours later she had the acute onset of lower abdominal pain and
obstipation
.
She presented to the emergency department and on physical examination there was mild abdominal distension with
tympany
and lower abdominal tenderness to deep palpation.
Slide4Later that night, she developed tachycardia and
tachypnea
.
Physical examination showed worsening abdominal distension and tenderness.
Blood tests revealed new
leukocytosis
, lactic
acidemia
, and
hypoalbuminemia
.
Slide5CT
of the abdomen and pelvis showed mildly dilated small bowel loops consistent with
ileus
.
She was admitted to the surgery service and a
nasogastric
tube was placed to suction with bilious output.
Slide6Repeat CT scans of the abdomen and pelvis showed persistently dilated small bowel loops and new
pneumatosis
intestinalis
with
pneumoperitoneum
(Figure A, B).
Slide7Slide8She underwent emergent exploratory
laparotomy
that revealed small bowel necrosis (Figure C).
Slide9Slide10Preoperative CT scans demonstrated evidence of small bowel obstruction and twisting of the mesentery in the left lower quadrant (Figure B, circle).
Intraoperative
findings demonstrated necrotic bowel internally herniated through an adhesion in the right lower quadrant from the
epiploica
of the sigmoid colon.
There was no evidence of perforation.
Slide11There was clear demarcation between healthy and necrotic bowel, and 160 cm of necrotic small bowel were
resected
with primary
anastomosis
.
Her postoperative course was complicated by peritonitis requiring treatment with antimicrobials, and she was discharged 10 days later.
Slide12Upon further questioning, she reported a several-month history of intermittent abdominal, right flank and right shoulder pain before colonoscopy that resolved after surgery.
Slide13We hypothesize that she had a preexisting symptomatic chronic internal hernia; small bowel then became strangulated through an adhesion, which may have been caused by
insufflation
and manipulation of the colon during colonoscopy.
She followed up in surgery clinic 5 days after discharge where she overall felt well and was maintaining adequate oral nutrition.
Slide14Small bowel obstruction as a risk of colonoscopy is exceptionally uncommon. Small bowel obstruction after colonoscopy has previously been associated with both internal hernias and adhesions.
Slide15There was a single case of mesenteric
torsion comparable
with our current patient found in the medical literature, in which the patient was managed conservatively without a need for surgical treatment.
Slide16However, our case demonstrates that intestinal necrosis requiring intestinal resection may also be encountered.
Awareness
of this rare but potentially life-threatening complication is critical in assessing any patient for
postcolonoscopy
complications.