HCMC_P_049062 - Hennepin County Medical Center

Case Reports
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Figure One: ED ultrasound of Morison's pouch, showing free
intraperitoneal fluid
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Figure Two: ED ultrasound showing free fluid surrounding the bladder
Use of ED Bedside Ultrasound to Direct the
Management of a Life-threatening
Complication of a Routine Procedure
Brian Driver, MD
Departments of Emergency Medicine and Internal Medicine
Hennepin County Medical Center
Abstract
Ultrasound use in the emergency department has
been shown to be time and cost efficient, and in
many cases, life saving. This case describes its use
to direct the management of an unusual complication
of routine colonoscopy.
Case Report
A 65-year-old woman presented to the emergency
department with altered mental status eleven hours
after a routine screening colonoscopy. She was at
home the evening after the procedure and telephoned
her neighbor for help. When he arrived, he found her
collapsed on the kitchen floor and immediately called
911. Emergency medical services emergently
transported her to a stabilization room.
On arrival, she appeared obtunded, pale, and
critically ill. A bedside ultrasound was immediately
performed revealing a large amount of free fluid in
her peritoneal cavity, instantly diagnostic of an intraabdominal
catastrophe (Figures One and Two).
Blood was called for, fluids where hung, and general
surgery was immediately paged to determine the
need for emergency operative intervention.
The differential diagnosis included, most prominently,
hemoperitoneum from an unknown source of bleeding
and viscus perforation with bowel contents spilling into
the abdomen. An upright chest radiograph failed to
show any pneumoperitoneum, making viscus perforation
less likely. The patient’s mental status, blood pressure,
and heart rate all improved with rapid fluid resuscitation.
As she was now hemodynamically stable, a CT of her
abdomen/pelvis was obtained, demonstrating severe
splenic injury with active extravasation of contrast
(Figure Three). She was taken emergently to the
operating room where she was found to have severe
avulsion of her splenic capsule. A splenectomy was
performed, and she was discharged on post-operative
day 7 with an otherwise uncomplicated hospital course.
Discussion
There are more than 14 million colonoscopies per
year in the United States, with a relatively low overall
complication rate of about 5 per 1,000 procedures.
Splenic injury from a colonoscopy is exceedingly
rare, with only approximately 95 case reports in the
English literature. This case is the first documented
report in which bedside ultrasound was utilized to
facilitate rapid diagnosis and treatment.
This particular injury occurs when excessive force
is applied downward at the splenic flexure during
colonoscopy, exerting traction on the splenocolic
ligament and ultimately the splenic capsule, which
then pulls free from the spleen (Figure Four). This
leaves the splenic parenchyma open to the abdomen,
with resultant, and often severe, bleeding. Usually, 75%
of patients with this injury will present within 24 hours
of colonoscopy. However, this diagnosis of colonoscopy.
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Figure Three: Abdominal Ct scan showing free fluid and active contrast
extravasation at the injury
12 | Approaches in Critical Care | January 2013