Colonoscopy Results in Severe Intestinal Perforation

This case involves a sixty-five-year-old female patient who underwent an endoscopy and colonoscopy after suffering from chronic anemia of unknown etiology. According to the medical record, the physician mentions that during the procedure, there was technical difficulty due to restrictions of movement of the colon and that a perforation of the sigmoid colon was suspected. He attributed the failure to sigmoid looping and noted a perforation at 18 cm while removing the scope camera. The patient had to undergo a sigmoid resection with end colostomy via the Hartmann procedure. As a consequence of the fair amount of peritoneal irritation and fluid in the pelvis, a decision was made not to attempt primary anastomosis.

Question(s) For Expert Witness

1. Is this an accepted outcome and how should the perforation have been recognized sooner to prevent such serious complications?

Expert Witness Response E-005898

Generally, a colonoscopy is a safe procedure and complications are rare. Such complications may include colonic perforation, bleeding, infection, abdominal distention, postpolypectomy coagulation syndrome, splenic rupture, small bowel obstruction, and medication effects. Mechanical perforation by the tip of the instrument occurs at sites of weakness of the colon wall (diverticula, transmural inflammation) and proximal to obstructing points (neoplasms, strictures). Pneumatic perforation of the colon or ileum results from distention by insufflated air. It should be able to be detected quite rapidly as fever and leukocytosis may eventually develop with any of these perforations. When plain abdominal or chest radiographs show pneumoperitoneum, gross extravasation should be assessed, and, if present, surgical intervention is required. In the absence of leakage, treatment with intravenous antibiotics and close observation may be considered. This would be a clinical determination.