Skip to main content

Colonoscopic perforations

Etiology, diagnosis, and management

Abstract

Since its introduction into clinical medicine, flexible fiberoptic colonoscopy has had a great impact on diagnosis and management of diseases of the colon and rectum. There are three mechanisms responsible for colonoscopic perforation: specifically, mechanical perforation directly from the colonoscope or a biopsy forceps, barotrauma from overzealous air insufflation, and, finally, perforations that occur during therapeutic procedures. Perforation of the colon, which requires surgical intervention more frequently than bleeding, occurs in less than 1 percent of patients undergoing diagnostic colonoscopy and may be seen in up to 3 percent of patients undergoing therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures. Management of colonic perforation secondary to colonoscopy remains a controversial issue in that it can be effectively managed by operative and nonoperative measures. If a perforation does occur, signs and symptoms that the patient will experience will be related to both the size and site of the perforation, adequacy of the bowel preparation, amount of peritoneal soilage, underlying colonic pathology (where a thin walled colon from colitis or ischemia, for example, may result in a larger perforation than a healthy colon), and, finally, overall clinical condition of the patient. Radiology often establishes diagnosis. Plain films of the abdomen and an upright chest x-ray may reveal extravasated air confined to the bowel wall, free intraperitoneal air, retroperitoneal air, subcutaneous emphysema, or even a pneumothorax. A localized perforation may demonstrate lack of pneumoperitoneum. Some surgeons recommend surgery for all colonoscopic perforations; however, there does appear to be a role for conservative management in a select group of patients such as those with silent asymptomatic perforations and those with localized peritonitis without signs of sepsis that continue to improve clinically with conservative management. Finally, conservative management works well in those patients with postpolypectomy coagulation syndrome. Surgery is most definitely indicated in the presence of a large perforation demonstrated either colonoscopically or radiographically and in the setting of generalized peritonitis or ongoing sepsis. The presence of concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion may force immediate surgery. Finally, in the patient who deteriorates with conservative management, one should proceed to surgery.

This is a preview of subscription content, access via your institution.

References

  1. Wolff WI, Shinya H. Colonofiberoscopy. JAMA 1971;217:1509–12.

    PubMed  Google Scholar 

  2. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic and therapeutic colonoscopies. Gut 1983;24:376–83.

    PubMed  Google Scholar 

  3. Heath B, Rogers A, Taylor A, Lavergne J. Splenic rupture: an unusual complication of colonoscopy. Am J Gastroenterol 1994;89:449–50.

    PubMed  Google Scholar 

  4. Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg 1994;179:333–7.

    PubMed  Google Scholar 

  5. Ghazi A, Grossman M. Complications of colonoscopy and polypectomy. Surg Clin North Am 1982;62:889–96.

    PubMed  Google Scholar 

  6. Shinya H. Complications: prevention and management. In: Colonoscopy, diagnosis and treatment of colonic diseases. Tokyo: Igaku-Shoin, 1982:199–208.

    Google Scholar 

  7. Waye JD. Colonoscopy: a clinical view. Mt Sinai J Med 1975;42:1–34.

    PubMed  Google Scholar 

  8. Williams C, Teague R. Colonoscopy. Gut 1973;14:990–1003.

    PubMed  Google Scholar 

  9. Burt CA. Pneumatic rupture of the intestinal canal with experimental data showing the mechanism of perforation and the pressure required. Arch Surg 1931;22:875–902.

    Google Scholar 

  10. Kozarek RA, Earnest DL, Silverstein ME, Smith RG. Airpressure induced colon injury during diagnostic colonoscopy. Gastroenterology 1980;78:7–14.

    PubMed  Google Scholar 

  11. Reeve T, Kukora JS. Pneumatic perforation of the colon during colonoscopy: is the hypermobile right colon a risk factor? Dis Colon Rectum 1984;27:751–3.

    PubMed  Google Scholar 

  12. Picciano LD, Hansel BC, Luchette FA. Insufflation: complications and recommendations. Surg Endosc 1995;9:834–7.

    PubMed  Google Scholar 

  13. Williams CB, Lane RH, Sakai Y. Colonoscopy: an air-pressure hazard. Lancet 1973;2:729.

    Google Scholar 

  14. Tedesco FJ. Colonoscopic polypectomy. In: Silvis SE, ed. Therapeutic Gastrointestinal Endoscopy. New York: Igaku-Shoin, 1985:269–288.

    Google Scholar 

  15. Nivatvongs S. Complications in colonoscopic polypectomy: lessons to learn from an experience of 1576 polyps. Am Surg 1988;54:61–3.

    PubMed  Google Scholar 

  16. Bigard MA, Gaucher P, Lassalle C. Fatal colonic explosion during colonoscopic polypectomy. Gastroenterology 1979;77:1307–10.

    PubMed  Google Scholar 

  17. Thomson SR, Fraser M, Stupp C, Baker LW. Iatrogenic and accidental colon injuries—what to do? Dis Colon Rectum 1994;37:496–502.

    PubMed  Google Scholar 

  18. Hall C, Dorricott NJ, Donovan IA, Neoptolomos JP. Colon perforation during colonoscopy: surgicalversus conservative management. Br J Surg 1991;78:542–4.

    PubMed  Google Scholar 

  19. O'Brien TS, Garrido MC, Dorudi S, Collin J. Delayed perforation of the colon following colonoscopic biopsy. Br J Surg 1993;80:1204.

    PubMed  Google Scholar 

  20. Rankin GB. Indications, contraindications, and complications of colonoscopy. In: Sivak MV, ed. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987: 868–80.

    Google Scholar 

  21. Lezak MB, Goldhammer M. Retroperitoneal emphysema after colonoscopy. Gastroenterology 1974;66:118–20.

    PubMed  Google Scholar 

  22. Fitzgerald SD, Denk A, Flynn M, Longo WE, Vernava AM. Pneumoperitoneum and subcutaneous emphysema of the neck: an unusual manifestation of colonoscopic perforation. Surg Endosc 1992;6:141–3.

    PubMed  Google Scholar 

  23. Barnett T, McGeehin W, Chen C, Brennan EJ. Acute tension pneumoperitoneum following colonoscopy. Gastrointest Endosc 1992;38:99–100.

    PubMed  Google Scholar 

  24. Winek TG, Mosely S, Grout G, Luallin D. Pneumoperitoneum and its association with ruptured abdominal viscus. Arch Surg 1988;123:709–12.

    PubMed  Google Scholar 

  25. Schwab G, Wetscher G, Waldenberger P, Bodner E. Retropneumoperitoneum: an unusual case after colonoscopy. Endoscopy 1993;25:256–7.

    PubMed  Google Scholar 

  26. Meyers MA, Ghahremani GL. Complications of fiberoptic endoscopy. Radiology 1975;115:301–7.

    PubMed  Google Scholar 

  27. McCollister DL, Hammerman HJ. Air, air, everywhere: pneumatosis cystoceles coli after colonoscopy. Gastrointest Endosc 1990;36:75–6.

    Google Scholar 

  28. Thomas JH, Pierce GE, MacArthur RI. Bilateral pneumothoraces secondary to colonic endoscopy. J Natl Med Assoc 1979;71:701–2.

    PubMed  Google Scholar 

  29. Stapokis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. Comput Assist Tomogr 1992;16:713–6.

    Google Scholar 

  30. Vincent M, Smith LE. Management of perforation due to colonoscopy. Dis Colon Rectum 1983;26:61–3.

    PubMed  Google Scholar 

  31. Soon JC, Shang NS, Goh PM, Rauff A. Perforation of the large bowel during colonoscopy in Singapore. Am Surg 1990;56:285–8.

    PubMed  Google Scholar 

  32. Christie JP, Marrazzo J. “Mini-perforation” of the colon—not all post-polypectomy perforations require laparotomy. Dis Colon Rectum 1991;34:132–5.

    PubMed  Google Scholar 

  33. Adair HM, Hishon S. The management of colonoscopic and sigmoidoscopic perforation of the large bowel. Br J Surg 1981;68:415–6.

    PubMed  Google Scholar 

  34. Carpio G, Albu E, Gumbs MA, Gerst PH. Management of colonic perforation after colonoscopy: report of three cases. Dis Colon Rectum 1989;32:624–6.

    PubMed  Google Scholar 

  35. Jentschura D, Raute M, Winter J, Henkel Th, Kraus M, Manegold BC. Complications in endoscopy of the lower gastrointestinal tract: therapy and prognosis. Surg Endosc 1994;8:672–6.

    PubMed  Google Scholar 

  36. Rogers BH, Silvis SE, Nebel DT, Sugawa C, Mandelstram P. Complications of flexible fiberoptic colonoscopy and polypectomy. Gastrointest Endosc 1975;22:73–7.

    PubMed  Google Scholar 

  37. Smith LE. Fiberoptic colonoscopy: complications of colonoscopy and polypectomy. Dis Colon Rectum 1976;19:407–12.

    PubMed  Google Scholar 

  38. Stone HH, Fabian TC. Management of perforating colon trauma. Ann Surg 1979;190:430.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

About this article

Cite this article

Damore, L.J., Rantis, P.C., Vernava, A.M. et al. Colonoscopic perforations. Dis Colon Rectum 39, 1308–1314 (1996). https://doi.org/10.1007/BF02055129

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02055129

Key words

  • Colonoscopy
  • Perforation
  • Management
  • Review