The Scope of the Problem: Imaging of Complications ... · Intraperitoneal Colonic Perforation...

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The Scope of the Problem: Imaging of Complications Following Optical Colonoscopy Aaron Harman, MD Kevin J. Chang, MD, FSAR Department of Diagnostic Imaging Rhode Island Hospital The Warren Alpert Medical School of Brown University

Transcript of The Scope of the Problem: Imaging of Complications ... · Intraperitoneal Colonic Perforation...

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The Scope of the Problem:

Imaging of Complications

Following Optical Colonoscopy

Aaron Harman, MD

Kevin J. Chang, MD, FSAR

Department of Diagnostic Imaging

Rhode Island Hospital

The Warren Alpert Medical School of

Brown University

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Disclosures

We have no relationships with

commercial interests to disclose.

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Goals and Target Audience

• Goals: To provide the learner with high-

yield information on imaging findings of

complications from optical colonoscopy.

• Target Audience: Radiology residents,

radiologists, and CT technologists.

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Background

• Optical colonoscopy has traditionally been

considered the gold standard for colorectal

cancer screening.

• Serious complications are reportedly rare

(0.1-0.3%), however given the increasing

volume of patients undergoing the procedure,

a significant number of patients are affected.

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Background

• The most common complications are

hemorrhage and large bowel perforation.

• Upright plain films of the chest and abdomen

can be helpful in identifying intraperitoneal

free air but are insensitive in detecting other

pathology.

• CT imaging plays a key role in the diagnosis

of complications as well as in treatment

planning.

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Colonic Perforation Mechanism:

1) Barotrauma caused by pneumatic dilatation

2) Direct trauma from the endoscope

• increased risk with polypectomy, stricture dilatation,

and stenting

Imaging Appearance: Extraluminal air may be

intraperitoneal, extraperitoneal, or both depending on the

segment of colon which was perforated.

Clinical Significance: This usually requires surgical

treatment, though there is increasing interest in

endoscopic clipping for localized perforations.

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Intraperitoneal Colonic Perforation

• Intraperitoneal portions of the colon include the

cecum, transverse colon, and the sigmoid

colon.

• The cecum, having the largest caliber of any

portion of the large bowel, is most susceptible

to barotrauma injury, as predicted by the law of

LaPlace.

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Intraperitoneal Colonic Perforation

Barotrauma perforations

tend to have larger

volumes of free air than

perforations due to direct

endoscope trauma.

66-year-old woman presented with

right shoulder pain following

colonoscopy. A large cecal

perforation was confirmed at the

time of surgery.

Lateral topogram (above)

and axial CT (right)

demonstrate a large

amount of free

intraperitoneal air.

Right: Coronal CT

demonstrates an

unremarkable cecum.

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Extraperitoneal Colonic Perforation

• Retroperitoneal portions of the colon include the

ascending colon, descending colon, and the rectum.

• Above: Large amount of retroperitoneal air predominantly

on the right, which was found to originate from an

ascending colonic perforation at the time of surgery.

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Extraperitoneal Colonic Perforation with

Extraabdominal Free Air • Free air may dissect through the fascial planes to extent

beyond the retroperitoneum.

Left: 78-year-old woman

presented with abdominal

pain and distention following

colonoscopy, found to have

pneumoretroperitoneum

(arrow), pneumomediastinum

(arrow) and subcutaneous

emphysema (arrow). Found to

have a perforation of the

ascending colon at the time of

surgery.

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Intraperitoneal and Extraperitoneal

Colonic Perforation

Above: Intraperitoneal and

extraperitoneal free air on CT.

Below: AP CXR demonstrates subdiaphragmatic

free air (arrow), pneumomediastinum (arrow), &

subcutaneous emphysema in the neck (arrow).

56-year-old woman presenting with swelling of face and neck

hours after colonoscopy with dilatation of a sigmoid stricture.

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Pneumatosis Coli

Air in the colonic wall (arrows) following colonoscopy may

be associated with perforation, or occur as a result of

barotrauma or biopsy without transmural perforation.

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Postpolypectomy Coagulation

Syndrome

Mechanism: Electrocautery injury following polypectomy

extends beyond the mucosa and submucosa to cause a

serositis.

Imaging Appearance: Localized colonic mural thickening at

the site of polypectomy with stranding of the pericolonic fat

but without frank free air

Clinical Significance: 1% or less of all polypectomies.

Usually self-limited; treated with bowel rest and antibiotics.

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Postpolypectomy Coagulation

Syndrome 63-year-old woman presents with right-

sided abdominal pain and chills which

began minutes after colonoscopy with

cecal polypectomy.

Coronal CT demonstrates mural

thickening (arrow) of the cecum with

metallic hemostatic clip. No free air.

The patient was admitted for 2 days,

treated with pain management and

antibiotics, and was discharged in

good condition.

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Splenic Laceration

Proposed mechanisms:

1) Direct trauma by endoscope

2) Traction on the splenocolic ligament or adhesions by

endoscope maneuvers

- increased risk with splenomegaly, adhesions, prior

pancreatitis, and inflammatory bowel disease

Imaging Appearance: Perisplenic hematoma with focal splenic

hypoattenuation

Clinical Significance: In hemodynamically unstable patients,

emergent endovascular embolization or splenectomy is

generally indicated. Stable patients may be observed.

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Splenic Laceration: Subcapsular

80-year-old man with acute abdominal pain following

colonoscopy earlier the same day. Axial and coronal CT

reformats show a subcapsular splenic hematoma of

mixed attenuation. He was hemodynamically stable

and was managed conservatively without surgery or

embolization.

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Splenic Laceration: Extracapsular Axial and coronal contrast-enhanced

CT images performed for abdominal

pain and hemodynamic instability

following colonoscopy demonstrate a

large perisplenic hematoma with

hyperdense active extravasation

(arrows), as well as hemoperitoneum

within the pelvis.

The patient was taken to

the OR where she

underwent a splenectomy.

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Hemorrhage

Mechanism: Hemorrhage can be intraluminal or extraluminal.

Intraluminal hemorrhage is most often due to polypectomy.

Extraluminal hemorrhage may be due to injury of blood

vessels adjacent to bowel during post-polypectomy cautery or

traction on the bowel wall during manipulation of the

colonoscope.

Imaging Appearance: Intraluminal hemorrhage may be

diagnosed with nuclear tagged-RBC scan, angiography, or

colonoscopy. Extraluminal hemorrhage manifests as a high-

density intraperitoneal or extraperitoneal fluid on CT.

Clinical Significance: Bleeding can be treated by endoscopic

clipping, endovascular embolization, or surgery.

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Hemoperitoneum

72-year-old man with left upper quadrant pain one week following

colonoscopy. Axial CT shows hyperdense free fluid in the pelvis

consistent with hemoperitoneum (arrow). No other abnormality

was noted on the remainder of the exam. The patient was

managed conservatively without surgery.

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Acute Diverticulitis

Mechanism: Colonoscope can cause mechanical injury to preexisting colonic diverticuli, or displace stool into and thereby obstruct diverticuli, leading to inflammation.

Imaging Appearance: On CT there is colonic wall thickening, pericolonic fatty stranding, and in cases of perforation, free air and/or a peripherally-enhancing fluid collection representing an abscess.

Clinical Significance: Uncomplicated diverticulitis is treated with symptomatic relief and IV antibiotics. Diverticulitis complicated by perforation may require percutaneous abscess drainage and/or partial colectomy.

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Acute Diverticulitis

73-year-old female with rectal bleeding following incomplete

colonoscopy. Axial and Coronal reformats from a CT colonography

show sigmoid wall thickening with pericolonic fatty stranding and an

adjacent fluid collection (arrows). Surgery confirmed acute on chronic

diverticulitis with an adherent left ovary.

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Intrathoracic Colonic Herniation

Mechanism: Either creation of a new diaphragmatic hernia or

exacerbation of an existing diaphragmatic defect from blunt

trauma of the colonoscope or colonic insufflation of air.

Imaging Appearance: Loop of colon herniating into the chest

through a diaphragmatic defect, possibly resulting in a bowel

obstruction.

Clinical Significance: Rare. Often asymptomatic, but

symptoms may arise long after the injury. May cause

gastrointestinal symptoms such as nausea or abdominal pain

and may lead to obstruction. May also cause respiratory

symptoms. Both asymptomatic and symptomatic hernias are

repaired surgically.

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Intrathoracic Colonic Herniation 67-year-old man with history of esophagectomy

and gastric pull-through for esophageal cancer 2

years earlier presented with abdominal pain and

dyspnea 1 day following colonoscopy.

Below: AP topogram demonstrates a dilated,

gas-filled structure in the left hemithorax (arrow)

with dilated proximal bowel.

Above: Sagittal CT demonstrates a

dilated, incarcerated loop of colon

herniating into the left hemithorax

(arrow) via a preexisting diaphragmatic

defect.

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Conclusion

• Despite widespread acceptance of optical

colonoscopy as the preferred modality for

colorectal cancer screening, there are

multiple documented complications.

• It is important to be familiar with the CT

findings of these complications so

appropriate treatment can be instituted.

• Increasing use of CT colonography for

primary screening could potentially avoid

a large portion of these procedural

complications.

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Author Correspondence

Information

Aaron Harman, MD

[email protected]

Kevin J. Chang, MD, FSAR

Director of CT Colonography

Rhode Island Hospital, The Miriam Hospital, &

Rhode Island Medical Imaging

[email protected]