colonoscopic perforation
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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Colonoscopic Perforation
Jared TorkingtonCardiff
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• Incidence• Aetiology• Avoidance• Treatment
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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
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Incidence
• 5% random sample of medicare patients
• >65 years 1991-1998• 39 286 colonoscopies• 35 298 flexi sig
Gatto et al 2003
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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
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Polypectomy
• 34,620 colons over 30 years• 31 perforations (0.09%)• 18 (58%) in therapeutic• 13 (42%) in diagnostic
Araghizadeh 2001
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Site
Iqbal 2005
31%
7%
64%
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Aetiology
• Direct penetration
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Aetiology
• Direct penetration
• Bowing
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Aetiology
• Direct penetration
• Bowing• Across a
stricture
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Aetiology
• Direct penetration
• Bowing• Across a
stricture• Barotrauma
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Diagnosis of perforation
• Subtle signs or acute abdomen
• 50% at colonoscopy, rest usually within 48 hrs
• Sepsis• CXR or CT
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Operation?
• Mechanism of perforation• Age and co-morbidity• Bowel prep• Severity of symptoms• Degree of sepsis
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Post polypectomy syndrome
• Localized signs• No systemic sepsis• Analogous to diverticulitis• Regular review• Systemic antibiotics
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Results
• 31 perforations• 16 (52%) after hot biopsy or
polypectomy• 3 (9%) barotrauma• 16 (52%) identified at the time
Araghizadeh 2001
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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
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Results - surgery
• 20 (65%)• 9 direct closure• 7 resection, primary
anastomosis• 4 resection and diversion
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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
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Other complications
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Summary
• Incidence 1:750• Several mechanisms• Role for conservative
management in small selected group
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