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SPLENIC LACERATION AND HEMORRHAGE FOLLOWING ROUTINE COLONOSCOPY IN A PATIENT ON ANTICOAGULATION THERPAY: A COMPLEX CASE MANAGEMENT
DEEPAK KUMAR^*1, Sunny Kumar², Muhammad Jahanzaib Khan¹, Kishore Kumar^3
1INTERNAL MEDICINE, Mather Hospital, Port Jefferson, NY; ²Wright Center for Graduate Medical Education, Scranton, PA; ³Geisinger Community Medical Center, Scranton, PA

Introduction:

Splenic injury following colonoscopy is a rare but potentially life-threatening complication, occurring in less than 0.01% of cases. Risk factors include prior abdominal surgeries, splenic adhesions, and anticoagulation therapy. This case highlights the management of a Grade V splenic injury in a 69-year-old female presenting with abdominal pain and hemodynamic instability after a routine colonoscopy.



Case presentation:

A 69-year-old female with a history of atrial fibrillation, transient ischemic attack, hypertension, and breast cancer presented to the emergency department with worsening abdominal and left shoulder pain, alongside hypotension, 12 hours status post-routine colonoscopy. Physical examination showed tenderness in the left upper quadrant, and initial lab work revealed a hemoglobin level of 11.2 g/dL. A CT scan identified an 11.2 x 11 x 13.1 cm peri splenic hematoma with active hemorrhage, consistent with a grade 5 splenic injury. Apixaban was withheld, and Andexanet alfa was used for reversal. Despite aggressive resuscitation, her hemoglobin dropped to 6.6 g/dL, and elevated lactate of 2.5, indicating potential hemorrhagic shock, leading to her transfer to the ICU. Consequently, with interventional radiology consultation, patient underwent urgent splenic angiogram revealed active bleeding from a lower pole segmental branch of the splenic artery, which was managed with embolization. Follow-up imaging demonstrated a progression to a grade III splenic injury, characterized by a mildly enlarged peri splenic hematoma and hemoperitoneum, without any signs of ongoing contrast extravasation. Moreover, surgical consultation also highlighted significant hemoperitoneum and a bleeding splenic lesion, shown on follow up imaging, leading to the necessity for splenectomy. The patient stabilized and was discharged on postoperative day five with a regimen of antibiotics and vaccinations.





Discussion:

Splenic injury post-colonoscopy, though rare, is a recognized complication, attributed tension on the splenocolic ligament or on preexisting adhesions (patient had a history of bowel resection for jejunal lipoma) due to manipulation of colon or as a result of direct injury to spleen during passage through splenic flexure. This case underscores the importance of early recognition and multidisciplinary management of splenic injuries in patients on anticoagulation therapy. Splenic artery embolization can be life saving and should be considered in severe injuries to preserve splenic function.


Fig 1: Peri splenic hematoma with active peri splenic hemorrhage extending beyond the splenic capsule into the perineum, consistent with a grade 5 splenic injury. Small volume abdominal and pelvic hemoperitoneum.

Fig 2: Splenic capsular injury/capsular rupture with mildly increased, large perisplenic hematoma and hemoperitoneum with now no evidence of current contrast extravasation. The lesion now can be classified as AAST grade III injury.

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