Post on 21-Feb-2016
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Colonoscopic Perforation
Jared TorkingtonCardiff
• Incidence• Aetiology• Avoidance• Treatment
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
Incidence
• 5% random sample of medicare patients
• >65 years 1991-1998• 39 286 colonoscopies• 35 298 flexi sig
Gatto et al 2003
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
Polypectomy
• 34,620 colons over 30 years• 31 perforations (0.09%)• 18 (58%) in therapeutic• 13 (42%) in diagnostic
Araghizadeh 2001
Site
Iqbal 2005
31%
7%
64%
Aetiology
• Direct penetration
Aetiology
• Direct penetration
• Bowing
Aetiology
• Direct penetration
• Bowing• Across a
stricture
Aetiology
• Direct penetration
• Bowing• Across a
stricture• Barotrauma
Diagnosis of perforation
• Subtle signs or acute abdomen
• 50% at colonoscopy, rest usually within 48 hrs
• Sepsis• CXR or CT
Operation?
• Mechanism of perforation• Age and co-morbidity• Bowel prep• Severity of symptoms• Degree of sepsis
Post polypectomy syndrome
• Localized signs• No systemic sepsis• Analogous to diverticulitis• Regular review• Systemic antibiotics
Results
• 31 perforations• 16 (52%) after hot biopsy or
polypectomy• 3 (9%) barotrauma• 16 (52%) identified at the time
Araghizadeh 2001
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
Results - surgery
• 20 (65%)• 9 direct closure• 7 resection, primary
anastomosis• 4 resection and diversion
Stable, CVSLocalised signsGood health
PeritonitisLarge defectPoor bowel prep
LAPAROTOMY
Erect CXR
Free AirNo Free Air
CT scan Big Perforation
Contained Perforation
Conservative Treatment NBO, IVI, Abs
Deterioration
Kavic 2001
Other complications
Summary
• Incidence 1:750• Several mechanisms• Role for conservative
management in small selected group