One reason for colonic perforation in diagnostic colonoscopy: looping of the colonoscope
Yusuf Yucel1 (dryusufyucel at yahoo dot com) #, Ahmet Seker1, Timucin Aydogan2, Abdullah Ozgonul1, Alpaslan Terzi1, Orhan Gozeneli1, Ali Uzunkoy1
1 Harran University, Faculty of Medicine, Department of General Surgery, Sanliurfa, Turkey. 2 Harran University School of Medicine, Gastroenterology Department, Sanliurfa, Turkey
# : corresponding author
DOI
http://dx.doi.org/10.13070/rs.en.2.1447
Date
2015-08-13
Cite as
Research 2015;2:1447
License
Abstract

A colonoscopy is an endoscopic procedure commonly used for the diagnosis, treatment and follow-up of lower gastrointestinal system diseases. Among the complications associated with a colonoscopy, perforation of the colon has the highest morbidity and mortality. The sigmoid colon is the most common perforation site due to colonoscopic looping in the colon. The perforation may be diagnosed clinically, radiologically or during the colonoscopy procedure. Its treatment is usually surgical. Endoscopic clipping can be applied in selected cases. An awareness of the mechanism underlying colonoscopic looping in the colon may help to prevent colonic perforations

Introduction

A colonoscopy is an endoscopic procedure commonly used for the diagnosis, treatment and follow-up of lower gastrointestinal system diseases [1]. In rare cases, the procedure can result in complications, such as bleeding/haemorrhage, intra-abdominal organ injury and colonic perforation [2]. Among the complications of a colonoscopy, perforation of the colon has the highest morbidity and mortality [3-5]. Colonic perforation occurs via three different mechanisms: mechanical, pneumatic and therapeutic [6]. The incidence of perforation of the colon in diagnostic colonoscopies is 0.03–0.8%, whereas it is 0.15–3% in therapeutic colonoscopies [7-9].

The purpose of this study was to examine the pathophysiology of colonic perforations in diagnostic colonoscopies caused by looping of the colonoscope in the sigmoid colon. We discuss the findings in relation to those of the current literature.

One reason for colonic perforation in diagnostic colonoscopy: looping of the colonoscope figure 1
Figure 1. A 6 cm perforation with irregular edges in the sigmoid colon detected during a colonoscopy.
Case Presentation
Case 1

A 78-year-old male patient underwent a colonoscopy because of rectal bleeding. The patient was suffering from a left inguinal hernia. We proceeded with the colonoscopy until we reached the hepatic flexure of the colon. The hepatic flexure, transverse colon, splenic flexure and descending colon were normal. However, a 6 cm perforation, with irregular edges, was present in the sigmoid colon [1]. The rectum appeared normal. We decided to perform an emergency laparotomy because of the perforation in the sigmoid colon. Primary, double-layer closure was performed upon being identified of full layer perforation in approximately 5–6 cm in sigmoid colon during laparotomy. No complications developed during the post-operative follow-up, and the patient was discharged. The patient made a full recovery.

Case 2

A 78-year-old female patient underwent a colonoscopy because of chronic constipation. The patient had a history of a caesarean operation. We proceeded with the colonoscopy until reaching the hepatic flexure. The hepatic flexure, transverse colon, splenic flexure and descending colon were normal. However, a perforation of4–5 cm, with irregular edges, was detected in the sigmoid colon. The rectum was normal. We decided to perform an emergency laparotomy because of the perforation in the sigmoid colon. Primary, double-layer closure was performed upon being identified of full layer perforation in approximately 4–5 cm in sigmoid colon during laparotomy. No complications developed during the post-operative follow-up, and the patient was discharged. She made a full recovery.

Case 3

A 77-year-old female patient underwent a colonoscopy because of chronic abdominal pain. The patient had a history of a total abdominal hysterectomy. We proceeded with the colonoscopy until the hepatic flexure. The hepatic flexure, transverse colon, splenic flexure and descending colon were normal. However, a perforation of approximately 6–7 cm, with irregular shaped edges, was present in the sigmoid colon. The rectum was normal. The patient underwent an emergency operation because of the colonic perforation. Primary, double-layer closure was performed upon being identified of full layer perforation in approximately 4–5 cm in sigmoid colon during laparotomy. The patient developed no complications during the post-operative follow-up, and she was discharged after making a full recovery.

One reason for colonic perforation in diagnostic colonoscopy: looping of the colonoscope figure 2
Figure 2. Schematic indication of development stages of the perforation as a result of looping of the colonoscope in the sigmoid colon. a) Colonoscope in the sigmoid colon, b) colonoscope in the splenic flexure, c) and the tip of the colonoscope in the hepatic flexure, showing the looped colonscope in the sigmoid colon and the resulting perforation.
Discussion

Colonic perforation is caused by perforating or lacerating the colon wall during a diagnostic colonoscopy [10]. perforation of the colon wall may occur as a result of considering lumen of diverticula as lumen of bowel, proceeding without seeing bowel lumen and while being passed from tumour stenosis field. Laceration of the colon wall can be caused by uncontrolled pushing of the looped colonoscope in the sigmoid colon [6, 7]. As the edge of colonoscopy was in hepatic flexure, transverse colon or splenic flexure, colonoscope was looped at sigmoid colon and lacerated this place (Fig. 2). Colonoscopic looping at the sigmoid colon was responsible for the perforations in all three cases in the present study.

Factors that increase the risk of perforating the colon include advanced age, diverticulosis, bowel obstruction, female sex, incisional and ventral hernias, post-operative abdominal and pelvic cohesions, improper bowel preparation before colonoscopy, an over-looped sigmoid colon and inexperience of the endoscopist [3, 4, 9, 10]. One of our cases was male. This 78-year-old patient also had a left inguinal hernia. The other two were female (77 and 78 years, respectively), one with a history of a caesarean section and one with a history of a total abdominal hysterectomy. All three patients had an excessively tortuous sigmoid colon.

Patients, irrespective of the administration of sedation or partial sedation, may suffer from acute abdominal pain due to peritoneal irritation caused by perforation of the colon during a colonoscopy. They may also suffer from abdominal distension due to the penetration of gas through the perforation and the entry of this gas into the abdomen. A perforated colon can be diagnosed clinically or radiologically. The perforation may also be detected while the colonoscope is being withdrawn. The Cases of colonic perforations during diagnostic colonoscopies have been described in the literature. knowledge that diagnosis of perforation in a diagnostic colonoscopy is established during procedure is also available in literature. In the three cases in the present study, the perforation was detected during a diagnostic colonoscopic procedure. As noted in the literature, the sigmoid colon is most commonly the site of the perforation [3-5, 7]. This is likely caused by the angle of the recto-sigmoid junction, the mobility of the sigmoid colon and the force that is applied in the sigmoid colon during the colonoscopy procedure.

Although the treatment of colonic perforation is generally surgical via open or laparoscopic surgery [8], it can also be conservative. The size of the perforation determines the treatment option [3]. Other factors that influence the treatment options are the clinical status of the patient, underlying colon pathology, cleanliness of the bowel, length of time between the perforation and the diagnosis and the surgeon’s judgment [6, 8]. The surgical treatment is generally in the form of primary closure rather than resection and anastomosis [5]. Endoscopic clipping, which is a conservative treatment, may also be applied in selected cases. Emergency open surgery was undertaken in our cases because the perforation was detected during the procedure, the patients had emptied their bowels properly, and they had fasted for 24 h prior to the procedure. We used an open surgical procedure and primary closure in all three patients because the edges of the perforation were wide and irregular.

Knowledge of the role of colonoscopic looping in the sigmoid colon in colonic perforations during diagnostic colonoscopies can help to prevent such perforations. Endoscopists should keep this important factor in mind during diagnostic colonoscopies.

References
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ISSN : 2334-1009