Colonoscopic Perforation

Jared Torkington

Cardiff

• 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