Colonoscopic Perforation

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Colonoscopic Perforation

• Jared Torkington
• Cardiff

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• Incidence
• Aetiology
• Avoidance
• Treatment

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Incidence

• Rates vary 1 in 200 to 1 in 5000
• St Marks no rate quoted
• BUPA hospitals no rate quoted
• Cleveland Clinic no rate quoted
• ACPGBI/BSG no info
• Mayo 1-3/1000, 23/1000 for polypectomy

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Incidence

• 5 random sample of medicare patients
• gt65 years 1991-1998
• 39 286 colonoscopies
• 35 298 flexi sig

Gatto et al 2003
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Results

• Colonoscopy 1.96/1000
• Flexi sig 0.88/1000
• OR 1.8 (CI 1.2-2.8)
• Increasing age, diverticular disease
• 2 or more comorbidities
• Risk of perforation decreased during the study
  period

Gatto et al 2003
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Polypectomy

• 34,620 colons over 30 years
• 31 perforations (0.09)
• 18 (58) in therapeutic
• 13 (42) in diagnostic

Araghizadeh 2001
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Site
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64
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Iqbal 2005
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Aetiology

• Direct penetration

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Aetiology

• Direct penetration
• Bowing

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Aetiology

• Direct penetration
• Bowing
• Across a stricture

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Aetiology

• Direct penetration
• Bowing
• Across a stricture
• Barotrauma

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Diagnosis of perforation

• Subtle signs or acute abdomen
• 50 at colonoscopy, rest usually within 48 hrs
• Sepsis
• CXR or CT

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Operation?

• Mechanism of perforation
• Age and co-morbidity
• Bowel prep
• Severity of symptoms
• Degree of sepsis

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Post polypectomy syndrome

• Localized signs
• No systemic sepsis
• Analogous to diverticulitis
• Regular review
• Systemic antibiotics

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Results

• 31 perforations
• 16 (52) after hot biopsy or polypectomy
• 3 (9) barotrauma
• 16 (52) identified at the time

Araghizadeh 2001
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Results - conservative

• 11 (35) managed conservatively
• Afebrile, localised tenderness and mild WBC rise
• 3 went onto surgery, 1 closure and defunction, 2
  closure only
• 1 percutaneous abscess drained
• 1 death

Araghizadeh 2001
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Results - surgery

• 20 (65)
• 9 direct closure
• 7 resection, primary anastomosis
• 4 resection and diversion

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Kavic 2001
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Other complications
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Summary

• Incidence 1750
• Several mechanisms
• Role for conservative management in small
  selected group

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