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Colonoscopic Perforation

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

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Colonoscopic Perforation

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  1. Colonoscopic Perforation Jared Torkington Cardiff

  2. Incidence • Aetiology • Avoidance • Treatment

  3. 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

  4. Incidence • 5% random sample of medicare patients • >65 years 1991-1998 • 39 286 colonoscopies • 35 298 flexi sig Gatto et al 2003

  5. 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

  6. Polypectomy • 34,620 colons over 30 years • 31 perforations (0.09%) • 18 (58%) in therapeutic • 13 (42%) in diagnostic Araghizadeh 2001

  7. Site 7% 64% 31% Iqbal 2005

  8. Aetiology • Direct penetration

  9. Aetiology • Direct penetration • Bowing

  10. Aetiology • Direct penetration • Bowing • Across a stricture

  11. Aetiology • Direct penetration • Bowing • Across a stricture • Barotrauma

  12. Diagnosis of perforation • Subtle signs or acute abdomen • 50% at colonoscopy, rest usually within 48 hrs • Sepsis • CXR or CT

  13. Operation? • Mechanism of perforation • Age and co-morbidity • Bowel prep • Severity of symptoms • Degree of sepsis

  14. Post polypectomy syndrome • Localized signs • No systemic sepsis • Analogous to diverticulitis • Regular review • Systemic antibiotics

  15. Results • 31 perforations • 16 (52%) after hot biopsy or polypectomy • 3 (9%) barotrauma • 16 (52%) identified at the time Araghizadeh 2001

  16. 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

  17. Results - surgery • 20 (65%) • 9 direct closure • 7 resection, primary anastomosis • 4 resection and diversion

  18. Stable, CVS Localised signs Good health Peritonitis Large defect Poor bowel prep Erect CXR LAPAROTOMY No Free Air Free Air CT scan Big Perforation Contained Perforation Conservative Treatment NBO, IVI, Abs Deterioration Kavic 2001

  19. Other complications

  20. Summary • Incidence 1:750 • Several mechanisms • Role for conservative management in small selected group

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