Arab Journal of Gastroenterology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case report
Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient Faraz Khan Luni a,⇑, Muhammad Zohaib Bawany b, Abdur Rahman Khan a, Ali Nawras b, Sandeep Vetteth c a
Internal Medicine Department, University of Toledo, United States Gastroenterology Department, University of Toledo, United States c Nephrology Department, University of Toledo, United States b
a r t i c l e
i n f o
Article history: Received 26 January 2014 Accepted 20 April 2014 Available online xxxx Keywords: Colonoscopy Haemoperitoneum Immunosuppression Complications Peritoneal dialysis
a b s t r a c t We present the case of a patient on peritoneal dialysis (PD) who had an uneventful oesophagogastroduodenoscopy and colonoscopy. His peritoneal dialysis after colonoscopy had bright red peritoneal dialysate. The patient was completely asymptomatic and a CT scan was performed which did not reveal any retroperitoneal haematoma and showed no signs of perforation or splenic tear. His PD dialysate cleared up with time. We do not find any such case in the literature in which a patient has had haemoperitoneum after a colonoscopy without any obvious cause to account for it. Our patient was unique due to his CAPD in combination with his immunosuppression for his kidney transplant which may have predisposed him to the intraperitoneal bleed after colonoscopy or it may just have been a normal phenomenon after colonoscopy. More studies need to be done as the realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety. Ó 2014 Arab Journal of Gastroenterology. Published by Elsevier B.V.
Introduction In the USA, colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms and for the screening and surveillance of colorectal neoplasia [1]. According to the Centers for Disease Control and Prevention (CDC), approximately 14.2 million colonoscopies were performed in 2002 [2]. Colonoscopy carries a very low risk of serious adverse event (2.8 per 1000 procedure) [1]. Infrequently, haemoperitoneum occurs, mostly involving damage to the spleen [2]. We report a case of a patient on continuous ambulatory peritoneal dialysis (CAPD) who developed haemoperitoneum after a colonoscopy.
Case report We present the case of a 45 year old Caucasian male with history of cadaveric renal transplant performed two months ago. The patient was on continuous ambulatory peritoneal dialysis (CAPD) for 21 months prior to the transplant. He had acute graft rejection after which his CAPD was restarted due to graft failure but his tacrolimus was continued. He presented to the transplant ⇑ Corresponding author. Tel.: +1 4193836320.
clinic feeling very weak and tired. He had no history of bleeding per rectum or of black stool. His haemoglobin was found to be 7.0 g/dl which had dropped from 8.5 g/dl about two months ago so he was admitted to the hospital for workup and transfusion. His MCV was 90.5 fL and thus anaemia work up was done which revealed a mixed picture of iron deficiency and anaemia of chronic disease due to chronic kidney disease. His faecal occult blood test (FOBT) was found to be positive. The patient’s peritoneal dialysis (PD) was temporarily stopped prior to the procedure and the abdomen was kept dry for 8 h after which he underwent oesophagogastroduodenoscopy (EGD) and colonoscopy to investigate the cause of the anaemia and positive FOBT. EGD was unremarkable. Colonoscopy showed mild to moderate diverticulosis in the descending and sigmoid colon. Random biopsies were taken from colonic mucosa to rule out Cytomegalovirus which were later reported as inconclusive. The procedure was uneventful apart from some looping of the colonoscope. The patient tolerated the procedure well and there were no immediate complications. His PD was restarted after the colonoscopy and was found to have bright red peritoneal dialysate (Fig. 1). The patient was completely asymptomatic, haemodynamically stable and his abdominal exam was unremarkable. His haemoglobin was stable. The peritoneal dialysate analysis showed 23,000 RBC/mm3 with 56 WBC/mm3. A CT scan was performed which did not reveal any retroperitoneal haematoma. Some free
E-mail address: [email protected] (F.K. Luni). http://dx.doi.org/10.1016/j.ajg.2014.04.006 1687-1979/Ó 2014 Arab Journal of Gastroenterology. Published by Elsevier B.V.
Please cite this article in press as: Luni FK et al. Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient. Arab J Gastroenterol (2014), http://dx.doi.org/10.1016/j.ajg.2014.04.006
2
F.K. Luni et al. / Arab Journal of Gastroenterology xxx (2014) xxx–xxx
Fig. 2. After 72 hours the peritoneal dialysate has started to clear.
Fig. 1. Bright red dialysate fluid after colonoscopy.
air was seen anterior to the liver. This was not concerning as pneumoperitoneum has been reported in 11–34% of patients undertaking CAPD, usually in the absence of symptoms [3]. There were no signs of perforation or splenic tear. Patient was managed conservatively and remained asymptomatic, haemodynamically stable with stable haemoglobin over the period of 72 h. His PD dialysate started to clear up with time (Fig. 2). After 72 h his dialysate was much clearer and patient clinical status remained unchanged therefore the patient was discharged home. Discussion Complications of colonoscopy are relatively rare despite its frequency. In a recent study of over 230,000 outpatient colonoscopies only 0.31% suffered complications, with the most common three being bleeding (0.22%), perforation (0.03%) and cardiorespiratory complications (0.06%) [4]. Some of the lesser known common complications of colonoscopies causing haemoperitoneum include infection, post-polypectomy coagulation syndrome, complications of anaesthesia, and splenic rupture [2]. Other documented causes of haemoperitoneum after colonoscopies include a torn mesenteric vessel, a ruptured epiploic appendix, and a necrosed intestinal leiomyosarcoma [1]. Splenic rupture is a rare but potentially lethal complication with an overall estimated incidence of 0.004 percent [2]. The major risk factors for these complications include inflammatory bowel disease, therapeutic procedures performed during colonoscopy and intraabdominal adhesions from prior abdominal surgeries. The three mechanisms of perforation during colonoscopy include mechanical perforation, over-zealous air insufflation, and a therapeutic procedure (e.g. polypectomy). Factors identified with increased chances of bleeding include male sex, higher age, nonscreening indication, biopsies, polypectomies and absence of sedation/analgesia, whereas increased chances of perforation include biopsies and polypectomies. The only discernable risk factor for cardiorespiratory complications was advanced age [2]. Our patient’s case was interesting as he had a colonoscopy which was uneventful. He had a biopsy performed but no other invasive procedures like polypectomy were done. Patients typically
present within 24 h following the procedure with diffuse abdominal pain or localised left upper quadrant pain with positive Kehr’s sign (referred left shoulder pain from splenic injury), hypovolaemia, tachycardia and anaemia due to massive haemoperitoneum [2]. Our patient was totally asymptomatic with no physical findings. We were concerned that this may be due to his immunosuppression which may mask symptoms with which immunocompetent patients may present. Apart from the immunosuppression a renal patient undergoing CAPD is potentially at a greater risk to develop haemoperitoneum after colonoscopy for a number of reasons. An increased bleeding tendency among dialysis patients is long recognised even when the PT, PTT, and platelet count are normal. Fortunately, such bleeding tendencies, if identified early, are usually successfully managed by giving cryoprecipitate or deamino-8-D-arginine vasopressin (DDAVP) [5]. Another possibility is that this bleeding into the peritoneum is a normal phenomenon after colonoscopy. Our case came into attention as our patient was on CAPD which caused concerns due to the obvious haemoperitoneum. The findings were more disturbing and did not reflect the condition of the patient as a small amount of blood can cause dramatic changes in the colour of the dialysate fluid. In conclusion, we could not isolate the cause of the bleeding but it seemed to be a complication from the colonoscopy as it happened immediately after the procedure. Our patient was unique due to his CAPD in combination with his immunosuppression due to the kidney transplant which may have predisposed him to the intraperitoneal bleed. More studies need to be done to see if the immunosuppression may have predisposed the patient to complications from colonoscopy or if it may just be a normal phenomenon after colonoscopy. The realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety. Conflict of interest The authors declared that there was no conflict of interest. References [1] Tagg W, Woods S, Razdan R, Gagliardi J, Steenbergen P. Hemoperitoneum after colonoscopy. Endoscopy 2008;40(Suppl. 2):E136–7. [2] Murariu D, Takekawa S, Furumoto N. Splenic rupture: a case of massive hemoperitoneum following therapeutic colonoscopy. Hawaii Med J 2010;69:140–1. [3] Saunders RN, Veitch PS, Nicholson ML. Pneumoperitoneum in capd peritonitis. J R Soc Med 2004;97:28–9. [4] Crispin A, Birkner B, Munte A, Nusko G, Mansmann U. Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 2009;41:1018–25. [5] Walshe JJ, Lee JB, Gerbasi JR. Continuous ambulatory peritoneal dialysis complicated by massive hemoperitoneum after colonoscopy. Gastrointest Endosc 1987;33:468–9.
Please cite this article in press as: Luni FK et al. Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient. Arab J Gastroenterol (2014), http://dx.doi.org/10.1016/j.ajg.2014.04.006
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case report
Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient Faraz Khan Luni a,⇑, Muhammad Zohaib Bawany b, Abdur Rahman Khan a, Ali Nawras b, Sandeep Vetteth c a
Internal Medicine Department, University of Toledo, United States Gastroenterology Department, University of Toledo, United States c Nephrology Department, University of Toledo, United States b
a r t i c l e
i n f o
Article history: Received 26 January 2014 Accepted 20 April 2014 Available online xxxx Keywords: Colonoscopy Haemoperitoneum Immunosuppression Complications Peritoneal dialysis
a b s t r a c t We present the case of a patient on peritoneal dialysis (PD) who had an uneventful oesophagogastroduodenoscopy and colonoscopy. His peritoneal dialysis after colonoscopy had bright red peritoneal dialysate. The patient was completely asymptomatic and a CT scan was performed which did not reveal any retroperitoneal haematoma and showed no signs of perforation or splenic tear. His PD dialysate cleared up with time. We do not find any such case in the literature in which a patient has had haemoperitoneum after a colonoscopy without any obvious cause to account for it. Our patient was unique due to his CAPD in combination with his immunosuppression for his kidney transplant which may have predisposed him to the intraperitoneal bleed after colonoscopy or it may just have been a normal phenomenon after colonoscopy. More studies need to be done as the realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety. Ó 2014 Arab Journal of Gastroenterology. Published by Elsevier B.V.
Introduction In the USA, colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms and for the screening and surveillance of colorectal neoplasia [1]. According to the Centers for Disease Control and Prevention (CDC), approximately 14.2 million colonoscopies were performed in 2002 [2]. Colonoscopy carries a very low risk of serious adverse event (2.8 per 1000 procedure) [1]. Infrequently, haemoperitoneum occurs, mostly involving damage to the spleen [2]. We report a case of a patient on continuous ambulatory peritoneal dialysis (CAPD) who developed haemoperitoneum after a colonoscopy.
Case report We present the case of a 45 year old Caucasian male with history of cadaveric renal transplant performed two months ago. The patient was on continuous ambulatory peritoneal dialysis (CAPD) for 21 months prior to the transplant. He had acute graft rejection after which his CAPD was restarted due to graft failure but his tacrolimus was continued. He presented to the transplant ⇑ Corresponding author. Tel.: +1 4193836320.
clinic feeling very weak and tired. He had no history of bleeding per rectum or of black stool. His haemoglobin was found to be 7.0 g/dl which had dropped from 8.5 g/dl about two months ago so he was admitted to the hospital for workup and transfusion. His MCV was 90.5 fL and thus anaemia work up was done which revealed a mixed picture of iron deficiency and anaemia of chronic disease due to chronic kidney disease. His faecal occult blood test (FOBT) was found to be positive. The patient’s peritoneal dialysis (PD) was temporarily stopped prior to the procedure and the abdomen was kept dry for 8 h after which he underwent oesophagogastroduodenoscopy (EGD) and colonoscopy to investigate the cause of the anaemia and positive FOBT. EGD was unremarkable. Colonoscopy showed mild to moderate diverticulosis in the descending and sigmoid colon. Random biopsies were taken from colonic mucosa to rule out Cytomegalovirus which were later reported as inconclusive. The procedure was uneventful apart from some looping of the colonoscope. The patient tolerated the procedure well and there were no immediate complications. His PD was restarted after the colonoscopy and was found to have bright red peritoneal dialysate (Fig. 1). The patient was completely asymptomatic, haemodynamically stable and his abdominal exam was unremarkable. His haemoglobin was stable. The peritoneal dialysate analysis showed 23,000 RBC/mm3 with 56 WBC/mm3. A CT scan was performed which did not reveal any retroperitoneal haematoma. Some free
E-mail address: [email protected] (F.K. Luni). http://dx.doi.org/10.1016/j.ajg.2014.04.006 1687-1979/Ó 2014 Arab Journal of Gastroenterology. Published by Elsevier B.V.
Please cite this article in press as: Luni FK et al. Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient. Arab J Gastroenterol (2014), http://dx.doi.org/10.1016/j.ajg.2014.04.006
2
F.K. Luni et al. / Arab Journal of Gastroenterology xxx (2014) xxx–xxx
Fig. 2. After 72 hours the peritoneal dialysate has started to clear.
Fig. 1. Bright red dialysate fluid after colonoscopy.
air was seen anterior to the liver. This was not concerning as pneumoperitoneum has been reported in 11–34% of patients undertaking CAPD, usually in the absence of symptoms [3]. There were no signs of perforation or splenic tear. Patient was managed conservatively and remained asymptomatic, haemodynamically stable with stable haemoglobin over the period of 72 h. His PD dialysate started to clear up with time (Fig. 2). After 72 h his dialysate was much clearer and patient clinical status remained unchanged therefore the patient was discharged home. Discussion Complications of colonoscopy are relatively rare despite its frequency. In a recent study of over 230,000 outpatient colonoscopies only 0.31% suffered complications, with the most common three being bleeding (0.22%), perforation (0.03%) and cardiorespiratory complications (0.06%) [4]. Some of the lesser known common complications of colonoscopies causing haemoperitoneum include infection, post-polypectomy coagulation syndrome, complications of anaesthesia, and splenic rupture [2]. Other documented causes of haemoperitoneum after colonoscopies include a torn mesenteric vessel, a ruptured epiploic appendix, and a necrosed intestinal leiomyosarcoma [1]. Splenic rupture is a rare but potentially lethal complication with an overall estimated incidence of 0.004 percent [2]. The major risk factors for these complications include inflammatory bowel disease, therapeutic procedures performed during colonoscopy and intraabdominal adhesions from prior abdominal surgeries. The three mechanisms of perforation during colonoscopy include mechanical perforation, over-zealous air insufflation, and a therapeutic procedure (e.g. polypectomy). Factors identified with increased chances of bleeding include male sex, higher age, nonscreening indication, biopsies, polypectomies and absence of sedation/analgesia, whereas increased chances of perforation include biopsies and polypectomies. The only discernable risk factor for cardiorespiratory complications was advanced age [2]. Our patient’s case was interesting as he had a colonoscopy which was uneventful. He had a biopsy performed but no other invasive procedures like polypectomy were done. Patients typically
present within 24 h following the procedure with diffuse abdominal pain or localised left upper quadrant pain with positive Kehr’s sign (referred left shoulder pain from splenic injury), hypovolaemia, tachycardia and anaemia due to massive haemoperitoneum [2]. Our patient was totally asymptomatic with no physical findings. We were concerned that this may be due to his immunosuppression which may mask symptoms with which immunocompetent patients may present. Apart from the immunosuppression a renal patient undergoing CAPD is potentially at a greater risk to develop haemoperitoneum after colonoscopy for a number of reasons. An increased bleeding tendency among dialysis patients is long recognised even when the PT, PTT, and platelet count are normal. Fortunately, such bleeding tendencies, if identified early, are usually successfully managed by giving cryoprecipitate or deamino-8-D-arginine vasopressin (DDAVP) [5]. Another possibility is that this bleeding into the peritoneum is a normal phenomenon after colonoscopy. Our case came into attention as our patient was on CAPD which caused concerns due to the obvious haemoperitoneum. The findings were more disturbing and did not reflect the condition of the patient as a small amount of blood can cause dramatic changes in the colour of the dialysate fluid. In conclusion, we could not isolate the cause of the bleeding but it seemed to be a complication from the colonoscopy as it happened immediately after the procedure. Our patient was unique due to his CAPD in combination with his immunosuppression due to the kidney transplant which may have predisposed him to the intraperitoneal bleed. More studies need to be done to see if the immunosuppression may have predisposed the patient to complications from colonoscopy or if it may just be a normal phenomenon after colonoscopy. The realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety. Conflict of interest The authors declared that there was no conflict of interest. References [1] Tagg W, Woods S, Razdan R, Gagliardi J, Steenbergen P. Hemoperitoneum after colonoscopy. Endoscopy 2008;40(Suppl. 2):E136–7. [2] Murariu D, Takekawa S, Furumoto N. Splenic rupture: a case of massive hemoperitoneum following therapeutic colonoscopy. Hawaii Med J 2010;69:140–1. [3] Saunders RN, Veitch PS, Nicholson ML. Pneumoperitoneum in capd peritonitis. J R Soc Med 2004;97:28–9. [4] Crispin A, Birkner B, Munte A, Nusko G, Mansmann U. Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 2009;41:1018–25. [5] Walshe JJ, Lee JB, Gerbasi JR. Continuous ambulatory peritoneal dialysis complicated by massive hemoperitoneum after colonoscopy. Gastrointest Endosc 1987;33:468–9.
Please cite this article in press as: Luni FK et al. Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient. Arab J Gastroenterol (2014), http://dx.doi.org/10.1016/j.ajg.2014.04.006
