Selected complications of colonoscopy – an anaesthetist’s point of view
Wybrane powikłania kolonoskopii – punkt widzenia anestezjologa
Anaesthesiology and Intensive Therapy Department, St. Anna Trauma Surgery Hospital, STOCER Mazovia Rehabilitation Center Sp. z o.o., Warsaw
Head of Department: Elżbieta Kurmin-Gryz, MD
Kolonoskopia należy do zabiegów wykonywanych powszechnie, zarówno w celu diagnostyki, jak i leczenia wielu schorzeń i objawów. Podczas wykonywania kolonoskopii mogą wystąpić groźne powikłania, takie jak krwawienie i perforacja jelita grubego, zwłaszcza u pacjentów podczas usuwania polipów jelita grubego. Najczęstszym powikłaniem po endoskopowym usuwaniu polipów jest krwawienie. Może ono wystąpić bezpośrednio po polipektomii lub po upływie godzin, a nawet dni od zabiegu. Ostre krwawienie po usunięciu polipów często jest natychmiast rozpoznawane i może być leczone endoskopowo. Do innych, nieendoskopowych sposobów leczenia krwawienia po kolonoskopii należą embolizacja angiograficzna i leczenie operacyjne. Nagła utrata dużej ilości krwi (krwawienie/krwotok wewnętrzny) do dolnego odcinka przewodu pokarmowego może powodować niestabilność krążeniową i konieczność leczenia operacyjnego w trybie natychmiastowym lub pilnym. Chociaż perforacja jelita grubego jest powikłaniem rzadkim, to może skutkować koniecznością wykonania operacji metodą na otwarto, wytworzenia stomii na jelicie grubym, powikłaniami septycznymi, przedłużonym pobytem w szpitalu, a nawet zgonem pacjenta. O postępowaniu z pacjentem po rozpoznaniu perforacji decyduje chirurg, który bierze pod uwagę przede wszystkim: miejsce i rozległość uszkodzenia (mikroperforacja czy rozległe uszkodzenie jelita), stan ogólny pacjenta i współistniejące patologie jelita grubego. Zarówno nagła laparotomia z powodu krwawienia do dolnego odcinka przewodu pokarmowego, jak i z powodu perforacji jelita grubego wymagają współpracy endoskopisty, chirurga i anestezjologa w okresie okołooperacyjnym.
Colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms, as well as for the screening and surveillance of colorectal neoplasia. Serious complications, such as bleeding and perforation, are reported in patients undergoing colonoscopy, especially during polypectomy. Bleeding is the most common complication of colonic polypectomy. It can occur immediately following polypectomy or be delayed from hours to up to days. Acute post-polypectomy haemorrhage is usually immediately apparent and amenable to endoscopic therapy. Nonendoscopic treatment modalities include angiographic embolization and surgery. Acute massive bleeding (internal bleeding/haemorrhage) into the lower gastrointestinal tract may cause hypovolaemia, which decreases cardiac output and tissue oxygen supply, which may require emergency surgery. Although colonic perforation is a rare complication, it is associated with a high rate of morbidity and mortality. This unpleasant complication could result in surgical intervention, stoma formation, intra-abdominal sepsis, prolonged hospital stay, and even death. An extra-intestinal structure identified during endoscopic examination is the most common clinical feature of colonic perforation. The management of patients with colonic perforation should be individualized based on patients’ clinical status and underlying diseases, the nature of perforation, and concomitant colorectal pathologies. Patients with both acute massive bleeding and lower gastrointestinal perforation may need emergency laparotomy, which requires perioperative cooperation of an endoscopist, a surgeon and an anaesthetist.
Recent years have witnessed a particularly noticeable development in minimally invasive surgery, including colonoscopy. This development is accompanied by advances in anaesthetic techniques. Full collaboration between surgical and anaesthetic teams, with mutual understanding of needs and expectations, is a necessary condition for the further development of endoscopic surgery. The use of diagnostic and therapeutic colonoscopy has increased since the introduction of flexible fibre endoscopes. Much significance is currently attached to one-day procedures. This faces anaesthetic teams with a range of challenges related to general anaesthesia and analgosedation, both of which are intended to protect the patient against pain and other unpleasant experiences during colonoscopy, and may also contribute to reduced frequency of hospitalisations. The more common use of colonoscopy is also associated with increased rates of complications after therapeutic colonoscopy, e.g. polypectomy. Since these complications are relatively rare and may be the reason for lawsuits for damages, no prospective randomised studies to assess their incidence have been conducted. The paper discusses the mechanism, diagnosis and management of the two most common colonoscopic complications, i.e. colonoscopic perforation and bleeding.
Lower gastrointestinal perforation
Lower GI perforation is defined as a traumatic loss of intestinal wall integrity. The extent of perforation can vary from microinjuries to extensive damage to the intestinal wall. Due to the varying level of intestinal preparation, overall patient’s health status and the time elapsed between perforation and diagnosis, the extent of injury has a significant impact on the treatment used and prognosis. Minor perforations are caused by direct mechanical trauma to the large intestine, such as forcing the endoscope tip through the intestinal diverticulum mistaken for the colonic lumen, lateral perforation of the colonic flexure or transverse tear at the site of a large tight bowel stenosis. Colonic perforation due to pressure forces during an attempt to improve visualisation by means of increased colonic distension under gas pressure is also theoretically possible. However, such mechanism is rare. It was shown in one of publications that gas pressure of 4.07 psi (about 52 mmHg) is necessary to rupture normal human intestine (1). A more recent study showed that sigmoid pressure of 169 mmHg is necessary for its rupture (2, 3). Mechanical intestinal trauma during biopsy and electrical or thermal injury associated with polypectomy and post-polypectomy electrocoagulation is another mechanism underlying colonic perforation. Extensive colon damage is less common and may be caused by lateral colonoscope compression on the distended colonic wall. This compression may lead to a longitudinal dissection of the sigmoid or transverse colon wall during attempts at proximal colonoscopic manoeuvres. This type of colonic tears is particularly dangerous due to large size and the fact that they often develop beyond the field of vision. If such a mechanism of colonic trauma is suspected, urgent surgical intervention is needed. The incidence of colonoscopic perforation is estimated at 0.2% for diagnostic and 0.6% for colonoscopy with colon wall biopsy (4), but it may be actually less common (5). About 50-60% of colonic perforations occur in the sigmoid colon and the rectum, while caecal perforations account for 10-20% of cases (6). Risk factors for colonoscopic perforation include age > 75 years and comorbidities, as well as diverticulosis and constipations in the case of screening (7). Indications for surgical treatment include peritoneal symptoms, unsuccessful conservative treatment and size of perforation (> 1 cm) (8). Conservative treatment is mainly used in stable patients, without peritoneal symptoms, with early diagnosis of perforation in the retroperitoneal part of the large intestine (9, 10).
Anaesthetic management in suspected colon wall damage
Monitoring and symptomatic treatment is recommended for all hemodynamically stable patients with radiologically confirmed pneumoperitoneum, with no symptoms of peritonitis or coexisting sepsis. This type of management allows to avoid unnecessary laparotomy. Lack of improvement after conservative treatment requires extended diagnosis and reassessment of patient’s condition. Indications for abdominal surgical revision include deterioration of the general condition, abdominal pain and distension, peritoneal manifestations, fever, tachycardia and increased inflammatory markers. Circulatory stable patients require close monitoring, temporarily discontinued oral nutrition, vascular access, fluid therapy and empirical antibiotic therapy. Patients with circulatory instability may require aesthetic management, including rapid restoration of cardiovascular stability, as well as appropriate antibiotic and adjuvant therapy before surgical treatment of colonic perforation. First of all, proper filling of the vascular bed should be ensured. The body’s response to colonic perforation may include fever, tachycardia, tachypnea and increased leukocytosis. Breathing movements of the abdominal wall are impaired. The patient’s breathing becomes shallow and fast with the involvement of intercostal muscles. Symptoms of hypovolaemia, such as reduced blood pressure, tachycardia and oliguria, may occur. If hypovolaemia is not compensated, rapid deterioration of patient’s condition, including cardiac arrest, is possible (11). The following laboratory tests are recommended: full blood cell count, electrolytes, renal and hepatic function, blood glucose and electrocardiography. Coagulogram and arterial-blood gas measurement should be performed in patients suspected of developing sepsis. Blood, urine and, if possible, peritoneal fluid should be collected for microbiology testing before the onset of antibiotic therapy. Chest and abdominal radiography in a standing position may show subphrenic gas accumulation. Intestinal paralytic obstruction is characterised by significantly distended loops of the small bowel. If the patient’s severe condition does not allow for an X-ray to be performed in a standing position, a lateral abdominal X-ray scan will be useful as it may show free gas between the edge of the liver and the abdominal wall. Free peritoneal fluid and gas following colonic perforation are seen as a fluid reservoir with a distinct transverse line separating fluid from gas. The aim of cardiovascular fluid resuscitation is to rapidly restore appropriate oxygen supply to peripheral tissues. Hypovolemia, which affects most patients, results from significant fluid shifts into the peritoneal space and the GI lumen. Hypovolemia compensation should be initiated by administering an IV infusion of 0.9 NaCl solution or some other crystalloid solution. Electrolyte disturbances and acid-base imbalance should also be compensated. Blood transfusion should be considered to maintain haemoglobin levels > 10 g/dL. Coagulation disorders should be corrected with fresh frozen plasma transfusion. Fluid therapy should be closely monitored based on fluid balance. Patients showing symptoms of dyspnoea require oxygen therapy. Once the material for microbiological testing is collected, empirical antibiotic therapy should be initiated in accordance with the recommendations on antibiotic therapy in intra-abdominal infections (12). If surgical intervention is necessary, general anaesthesia with endotracheal intubation and controlled ventilation is a method of choice. Almost all laparotomies in colonic perforation are considered urgent, and thus require careful assessment and ensuring airway patency. It should be ensured that appropriate equipment and trained medical personnel are available in the operating room in case of difficulties in endotracheal intubation. Standard intraoperative monitoring should be used in circulatory stable patients. Circulatory unstable patients may require extended invasive monitoring. Intraoperative normothermia, as well as normal water/electrolyte and acid/base parameters should be maintained. Patients at advanced age with significant comorbidities who develop manifestations of sepsis or organ dysfunction should be postoperatively managed in the anaesthesiology and intensive care unit. The lungs should be oxygenated with 100% oxygen using a face mask before the induction of general anaesthesia. The induction of general anaesthesia is accompanied by endotracheal intubation by direct laryngoscopy using a laryngoscope. A muscle relaxant, usually succinylcholine, is used to facilitate the procedure. For patients with hyperkalemia or other contraindications to succinylcholine, a non-depolarising muscle relaxant, i.e. rocuronium, should be administered (13). Short-acting intravenous anesthetics, such as ketamine, etomidate, slow administration of propofol, and titrated doses of thiopental are used for intravenous induction. Since most medications used for intravenous induction and inhaled anesthetics cause vascular bed relaxation and reduce myocardial contractility, the induction of general anesthesia should be carefully considered, the anesthetics used should be titrated in small doses and the patient’s response to these agents should be monitored. Ketamine and midazolam are safer in circulatory unstable patients. In the case of intravenous induction, the anesthetic may be supplemented with an opioid analgesic (fentanyl, sufentanil, alfentanil, remifentanil). If hypoxia is observed intraoperatively, the concentration of oxygen in the respiratory gases should be increased so that the arterial oxygen saturation stays above 90% and the positive end-expiratory pressure (PEEP) should be used in the anesthetic apparatus. Intraoperative hypothermia should be avoided as it affects platelet function and thus leads to impaired coagulation (14). Most centers use atmospheric air for insufflation of the colon during colonoscopy. In some centers carbon dioxide is used instead to reduce pain. Extraperitoneal colonic perforation may be a diagnostic problem. Simultaneously performed physical examination and imaging tests fail to show an acute surgical disorder requiring urgent surgical intervention.
Lower gastrointestinal bleeding
The presence of blood in the stool after colonoscopy (especially after colonoscopy with colon biopsy) does not necessarily indicate a complication. Post-colonoscopic lower gastrointestinal bleeding is defined as bleeding requiring the initiation of medical management (endoscopic bleeding control, blood transfusion, surgery). Bleeding may occur during or immediately after colonoscopy or may be delayed up to several hours and even days after the procedure. The incidence of this complication depends on whether diagnostic or therapeutic colonoscopy was performed. The risk of bleeding during polypectomy is significantly greater compared to diagnostic colonoscopy. According to different researchers, the incidence of clinically significant bleeding is less than 0.1% after diagnostic colonoscopy and 1-2% after polypectomy (15-19).
Anaesthetic management in significant bleeding
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1. Burt CAV: Pneumatic rupture of the intestinal canal. Arch Surg 1931; 22: 875-902.
2. Yin WB, Hu JL, Gao Y et al.: Rupture of sigmoid colon caused by compressed air. World J Gastroenterol 2016; 22(10): 3062-3065.
3. Choi PW: Colorectal perforation by self-induced hydrostatic pressure: a report of two cases. J Emerg Med 2013; 44(2): 344-348.
4. Hassan MA, Thomsen CØ, Vilmann P: Endoscopic treatment of colorectal perforations – a systematic review. Dan Med J 2016; 63(4): pii: A5220.
5. Shi X, Shan Y, Yu E et al.: Lower rate of colonoscopic perforation: 110,785 patients of colonoscopy performed by colorectal surgeons in a large teaching hospital in China. Surg Endosc 2014; 28(8): 2309-2316.
6. Shin DK, Shin SY, Park CY et al.: Optimal Methods for the Management of Iatrogenic Colonoscopic Perforation. Clin Endosc 2016; 49(3): 282-288.
7. Gatto NM, Frucht H, Sundararajan V et al.: Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst 2003; 95: 230-236.
8. Seewald S, Soehendra N: Perforation: part and parcel of endoscopic resection? Gastrointest Endosc 2006; 63: 602-605.
9. Iqbal CW, Cullinane DC, Schiller HJ et al.: Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 2008; 143: 701-707.
10. Taku K, Sano Y, Fu KI et al.: Iatrogenic perforation associated with therapeutic colonoscopy: A multicenter study in Japan. J Gastroenterol Hepatol 2007; 22: 1409-1414.
11. Rosoff L, Weil M, Bradley EC, Berne CJ: Hemodynamic and metabolic changes associated with bacterial peritonitis. Am J Surg 1967; 114: 180-189.
12. Mazuski JE, Sawyer RG, Nathens AB et al.: The surgical infection society guidelines on antimicrobial therapy for intraabdominal infections: An executive summary. Surg Infect 2002; 3: 161-173.
13. Perry JJ, Lee JS, Sillberg VAH, Wells GA: Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of systemic reviews 2008; 2: CD002288.
14. Insler SR, Sessler DI: Perioperative thermoregulation and temperature monitoring. Anesthesiol Clin 2006; 24: 823-837.
15. Amato A, Radaelli F, Dinelli M et al.: Early and delayed complications of polypectomy in a community setting: The SPoC prospective multicentre trial. Dig Liver Dis 2016; 48(1): 43-48.
16. Kumar AS, Lee JK: Colonoscopy: Advanced and Emerging Techniques – A Review of Colonoscopic Approaches to Colorectal Conditions. Clin Colon Rectal Surg 2017; 30(2): 136-144.
17. Ma MX, Bourke MJ: Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon. Best Pract Res Clin Gastroenterol 2016; 30(5): 749-767.
18. Reumkens A, Rondagh EJ, Bakker CM et al.: Post-Colonoscopy Complications: A Systematic Review, Time Trends, and Meta-Analysis of Population-Based Studies. Am J Gastroenterol 2016; 111(8): 1092-1101.
19. Feagins LA: Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017. pii: S0002-9343(17)30244-9.
20. Eckman MH, Erban JK, Singh SK et al.: Screening for the risk for bleeding or thrombosis. Ann Intern Med 2003; 138: W15-W24.
21. Kozek-Langenecker SA, Afshari A, Albaladejo P et al.: Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30(6): 270-382.
22. Paluszkiewicz P, Mayzner-Zawadzka E, Baranowski W et al.: Zalecenia postępowania w masywnym krwotoku pourazowym lub okołooperacyjnym. Sepsis 2011; 5: 341-351.
23. Von Renteln D, Bouin M, Barkun AN: Current standards and new developments of colorectal polyp management and resection techniques. Expert Rev Gastroenterol Hepatol 2017; 23: 1-8.
24. Thirumurthi S, Raju GS: Management of polypectomy complications. Gastrointest Endosc Clin N Am 2015; 25(2): 335-357.
25. Klein A, Bourke MJ: Advanced polypectomy and resection techniques. Gastrointest Endosc Clin N Am 2015; 25(2): 303-333.
26. Lüning TH, Keemers-Gels ME, Barendregt WB et al.: Colonoscopic perforations: a review of 30,366 patients. Surg Endosc 2007; 21(6): 994-997.
27. Cobb WS, Heniford BT, Sigmon LB et al.: Colonoscopic perforations: incidence, management, and outcomes. Am Surg 2004; 70(9): 750-757.
28. Sethi A, Song LM: Adverse events related to colonic endoscopic mucosal resection and polypectomy. Gastrointest Endosc Clin N Am 2015; 25(1): 55-69.
29. Vernava AM III, Moore BA, Longo WE et al.: Lower gastrointestinal bleeding. Dis Colon Rectum 1997; 40: 846-858.
30. Johnson H Jr: Management of major complications encountered with flexible colonoscopy. JNMA 1993; 85: 916-920.
31. Gibbs DH, Opelka FG, Beck DE et al.: Postpolypectomy colonic hemorrhage. Dis Colon Rectum 1996; 39: 806-810.