In one scenario, an experienced gastroenterologist performed a routine, open-access surveillance colonoscopy on a 63-year-old male patient who was in otherwise good health. His past medical history indicated only some controlled hypertension and a previous open cholecystectomy many years ago. The colonoscopy was uneventful. The patient complained of some mild crampy abdominal discomfort in recovery. After being reassured that was normal and should settle, he was discharged^.
Fourteen hours later, the patient presented to the local emergency department by ambulance with progressive abdominal pain and left shoulder pain and had a syncopal episode when he got up to vomit. He was hypotensive and tachycardic on arrival, and a CT scan following resuscitation revealed haemoperitoneum and a splenic hilum tear. He underwent an emergency splenectomy and was discharged a few days later.
The gastroenterologist was unaware of the complication until he received a notification from Ahpra about the patient’s complaint. The patient also filed a civil claim against the gastroenterologist and hospital, alleging negligence, inappropriate discharge and failure to warn of the risk of a splenic injury after a colonoscopy.
In this scenario, Avant would defend the civil claim and respond to the Ahpra complaint.
Splenic injury risk
Approximately one million colonoscopies are performed in Australia every year1, with a significant proportion occurring in the private sector. Most adverse events associated with colonoscopies are minor and relate to preparation, sedation, bleeding or infection.2
The risk of a serious adverse event following a colonoscopy is about 0.2%, with perforation representing half of these – about 1000 each year in Australia.2 Splenic injury is estimated to occur at a rate of 0.02%, but with a mortality rate of 5-10%3,4. Therefore, about 10-20 people will die each year in Australia from splenic injury following a colonoscopy, indicating splenic injury is an emerging issue.
Mechanism of injury
The mechanism of injury is thought to be due to tension on the spleen from the splenocolic ligament or adhesions, leading to intracapsular haematoma or a tear to the body, or hilum of the spleen. Previous upper abdominal surgery and other splenic pathology are probably the only identifiable pre-procedural risk factors. Difficulty during the procedure to negotiate the bowel can also increase the risk.
While management may be conservative (usually intracapsular haematomas), many patients will require surgery or interventional radiology. As this complication is rare and often unrecognised, delay in diagnosis is common. It usually occurs within 12 hours of the colonoscopy, with abdominal pain, shoulder tip pain and hypotension. However, delayed and atypical presentations do occur.
Warning patients of the risk
Despite its rarity and often unpredictable occurrence, splenic injury can sometimes lead to patient complaints and litigation. When you consider the average patient’s perspective, this is unsurprising – a rare but significant complication such as this can be misunderstood.
While warning patients of this rare complication is unlikely to stop them consenting to a colonoscopy, being aware of it can go a long way to avoiding patient dissatisfaction and legal action. Importantly, while the referring doctor will be involved in the consent process, particularly with open access colonoscopy, the person performing the procedure is ultimately responsible to ensure informed consent has been obtained. The clinical indication for the colonoscopy is also relevant to medico-legal risk.
The best defence is a consent discussion where the risks and benefits of having a colonoscopy is provided to the patient, focusing on their specific situation and what is important to them.
Doctors should consider and assess the risk of iatrogenic splenic injury in each patient and warn them of this risk, as appropriate, during the consent discussion. The discussion should be documented in the medical records, together with a signed consent form.
It’s prudent to reinforce the importance of post-procedural instructions to your patients. Clearly indicate the need for immediate review if the patient experiences unexpected abdominal or shoulder pain, or lightheadedness, and how they can access this review.
- Consider and assess the risk of iatrogenic splenic injury in each patient and document your consent discussion.
- Reinforce the importance of post-procedure instructions and flag symptoms which would necessitate immediate review.
- Consider an early CT scan and involvement of a surgeon if a patient experiences abnormal abdominal pain after a colonoscopy.
^The scenario in this article is based on some similar cases.
If you require medico-legal advice on this issue, you can contact our medico-legal advisers via email at email@example.com or call 1800 128 268, available 24/7 in emergencies.
3 Singla S, Keller D, Thirunavukarasu P, Tamandl D, Gupta S, Gaughan J, Dempsey D. Splenic injury during colonoscopy--a complication that warrants urgent attention. J Gastrointest Surg. 2012 Jun;16(6):1225-34.
4 Ullah W, Rashid MU, Mehmood A, Zafar Y, Hussain I, Sarvepalli D, Hasan MK. Splenic injuries secondary to colonoscopy: Rare but serious complication. World J Gastrointest Surg 2020; 12(2): 55-67.