Gastroenterology
Volume 138, Issue 2 , Page 434, February 2010

Colonoscopy: An Unusual Complication

  • Adam C. Alder, MD

      Affiliations

    • Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
    • ,
  • Daniel L. Scott, MD

      Affiliations

    • Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
    • ,
  • Jeffrey D. Browning, MD

      Affiliations

    • Department of Internal Medicine and Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas, Texas

published online 23 December 2009.

David A. Katzka and David L. Jaffe, Section Editors

Article Outline

 

See related article, Ko CW et al, on page 166 in CGH.

Question: A 55-year-old man was referred to the ambulatory surgical center for screening colonoscopy. At presentation his past and current medical histories were unremarkable. After informed consent was obtained, the patient was prepared for colonoscopy. The colonoscope was easily passed to the level of the splenic flexure, at which point tortuosity and resistance to forward motion were encountered. This region was eventually traversed and what was thought to be the hepatic flexure was reached. Attempts to reduce the colonoscope in preparation for the final push to the cecum were met with extreme resistance, yielding an inability to remove the endoscope with simple traction. Via a combination of torque and alternating between gently pushing and pulling the colonoscope, the resistance to traction abated and the colonoscope fell back to the level of the splenic flexure. Inspection of this region revealed a large mucosal laceration. The edges of this laceration were apposed with endoclips, the colonoscope withdrawn, and the procedure aborted. Post-procedure, the patient's abdomen was soft and he had normal bilateral breath sounds.

The patient maintained hemodynamic stability with a benign physical examination during the post-procedure period. A complete blood count and flat-and-upright abdominal series were obtained immediately after the procedure (Figure A). The blood test was normal and the abdominal series revealed no evidence of free intraperitoneal air; however, a segment of transverse colon containing intraluminal endoclips was noted to lie above the diaphragm. The radiographic findings prompted transfer to the emergency room for further evaluation. What is your diagnosis?

Look on page 794 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 434): Congenital Morgagni Hernia With Colonic Incarceration Secondary to Colonoscopy 

The radiographic findings are most consistent with a diagnosis of congenital Morgagni hernia with colonic incarceration secondary to colonoscopy. Chest and abdominal computed tomography (CT) obtained in the emergency room confirmed a large anterior diaphragmatic defect with herniated colon containing intraluminal endoclips (Figure B).

The patient was admitted, monitored, and then taken electively to the operating room for laparoscopic repair. The transverse colon and omentum were found in a 10 × 2.5-cm anterior midline diaphragmatic defect (Figure C). There was no evidence of perforation or gangrenous changes of the incarcerated colon. The contents of the hernia sac were easily reduced and the defect was closed with pledgeted, nonabsorbable, horizontal mattress sutures using a percutaneous suture passer. The patient recovered completely and had no complications or signs of recurrence at 1-month follow-up.

To our knowledge, this is the first report of an asymptomatic congenital diaphragmatic hernia in an adult diagnosed as a consequence of screening colonoscopy. The vast majority of congenital diaphragmatic hernias are diagnosed in the prenatal or newborn period. Fewer than 10% of cases present in adulthood.1 The anterior, and generally asymptomatic, Morgagni hernia is the rarest form of congenital diaphragmatic hernia, with the posterolateral Bochdalek hernia accounting for >85% of such cases. There are several reports in the literature of undiagnosed traumatic diaphragmatic hernias being encountered during colonoscopy2, 3 with surprisingly high mortality. As a result, endoscopists should maintain a high index of suspicion in individuals with a history of blunt force or penetrating trauma to the chest or abdomen and obtain a pre-procedure chest radiograph. Likewise, there should be low threshold for intra- or post-procedure fluoroscopic or radiographic evaluation if significant difficulties are encountered while attempting to reduce the colonoscope. All diaphragmatic defects should be repaired regardless of the presence or absence of symptoms at the time of diagnosis. Currently, a laparoscopic approach is advocated for repair of these diaphragmatic defects.

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References 

  1. Langham MR, Kays DW, Ledbetter DJ, et al. Congenital diaphragmatic hernia (Epidemiology and outcome). Clin Perinatol. 1996;23:671–688
  2. Baumann UA, Mettler M. Diagnosis and hazards of unexpected diaphragmatic hernias during colonoscopy: report of two cases. Endoscopy. 1999;31:274–276
  3. Chae HS, Kim SS, Han SW, et al. Herniation of the large bowel through a posttraumatic diaphragmatic defect during colonoscopy: report of a case. Dis Colon Rectum. 2002;45:1261–1262

 Conflicts of interest The authors disclose no conflicts.

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(09)01874-5

doi:10.1053/j.gastro.2009.08.072

Gastroenterology
Volume 138, Issue 2 , Page 434, February 2010

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