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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
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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 7% 64% 31% Iqbal 2005
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, CVS Localised signs Good health Peritonitis Large defect Poor bowel prep Erect CXR LAPAROTOMY No Free Air Free Air CT scan Big Perforation Contained Perforation Conservative Treatment NBO, IVI, Abs Deterioration Kavic 2001
Summary • Incidence 1:750 • Several mechanisms • Role for conservative management in small selected group