64 year old female scheduled for screening colonoscopy at outpatient surgery center. Patient on maintenance dose of opioids for underlying, chronic orthopedic issue. Had a earlier colonoscopy, years prior, where poor bowel prep was found. For the colonoscopy at issue, poor bowel prep and severely limited visualization was found throughout the bowel and procedure was considered non-diagnostic. The entire procedure lasted 10 minutes. Withdrawal time of approximately 2-3 minutes. Patient discharged. Three days later, patient found deceased by family. Autopsy revealed laceration of the spleen with surrounding, significant hematoma. Mechanism of injury was not a bowel perforation, but rather splenocolic ligament pulled from capsule via force of the procedure.
Issues include (1) sufficiency of prescribed bowel prep prior to procedure, (2) decision to proceed with procedure upon encountering poor bowel prep and limited visualization and (3) procedure and withdrawal times. An additional issue exists as to office post-procedure policy relating to patient follow-up telephone calls in terms of numbers and time frames that may not have been followed.,
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Do you believe there might have been medical error?
While splenic injury is a known (albeit fairly rare) complication of a colonoscopy, if a poor prep is found, it is not prudent to proceed with the procedure. Poor visualization due to a poor prep can lead to overinflation, more pressure on the scope than necessary, which cause this injury. The procedure probably should have been aborted if the prep was poor. The withdrawal time in this case is not relevant.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above; the extra pressure needed to maneuver the scope, due to the poor prep, made splenic injury more likely.
What makes you a good expert for this case?
Have performed > 25,000 colonoscopies, approximately 1 in 7000 complications, never sued.
How often do you encounter cases similar to this one in your practice?
Have seen 3 splenic injuries, one caused by my procedure (15 years ago) and two by colleagues. My patient was quickly treated and was fine.
Do you believe there might have been medical error?
The cause of a splenic injury on a colonoscopy is most commonly looping of the scope. Keeping the scope straight reduces this risk. It is more challenging to keep the scope straight when the bowel prep is inadequate. This assumes that the scope made it past the splenic flexure - if the procedure was aborted in the sigmoid colon, then it would be very unlikely that the injury was caused by the procedure
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As stated above, with the inadequate prep, it is difficult to keep the scope straight and results in looping which can put pressure on the spleen
What makes you a good expert for this case?
I am an academic gastroenterologist and have experience with colonoscopy and teaching fellows colonoscopy.
How often do you encounter cases similar to this one in your practice?
This is a rare complication of a colonoscopy but certainly one that has been described in the literature
Do you believe there might have been medical error?
Splenic laceration is a rare, yet known complication of colonoscopy. The problem in this case deals with the preparation. The poor prep in the past could portend a poor prep in the future, but not always as we don’t know the reason for the poor prep in the past. However, if this procedural prep was poor and non-diagnostic why was the colonoscopy continued. Sometimes one sees a poor prep, but thinks they can clean it avoiding having to repeat the procedure. That doesn’t seem to be the case in this patient as the procedure was only 10 minutes, with a 3 min withdrawal and it doesn’t seem like time was taken to clean enough to make the procedure worthwhile. The question then becomes why would you put the patient at risk for completing the colonoscopy if you knew it would need to be repeated anyway. It is hard to comment on the post procedure aspect with what is given here, however usually patients develop significant abdominal pain after a splenic laceration and would contact the doctor or present to and ER.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the preparation was poor and the procedure was going to be non-diagnostic then consideration for aborting the procedure should have been taken. The poor visualization could have made the procedure more difficult and continuing the colonoscopy led to the injury.
What makes you a good expert for this case?
I am an experienced academic gastroenterologist who is well respected in the field. I have done many thousands of colonoscopies, including higher risk, advanced therapeutic procedures, and understand how complications occur. In addition, I teach endoscopy to new fellows on a daily basis and understand the limitations of our craft.
How often do you encounter cases similar to this one in your practice?
This is a very rare complication. I believe I have seen this 2-3 times over my career.
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