Had an interesting case: blood and peritoneal signs

[pinipig523]

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So we had this pt come in post-colonoscopy who actually had a syncopal event after the procedure. The GI attending called the ER and spoke to our attending and said that it was likely post-procedural vasovagal reaction but that the patient had to be evaluated... ok, no problem.

So the pt came down bradycardic to 40 but nothing on EKG and nothing on trop. The pressure began to drop a little to the 90s (sbp) and we began to think there was a bleed to this and that there was more than meets the eye.

The belly felt fine.... but on FAST, large fluid in Morrison's pouch!! CTap showed a large bleed. Hgb came back at 7 (from 13)!!

But the belly still felt benign... I recall my trauma attending telling me that it takes approx 6 hours for blood to cause peritonitis. Has this been your experience? Have you guys noted no peritoneal signs in a patient with blood in the belly (not to mention several liters of blood??)?

Bile can cause earlier peritoneal findings and so can gastric secretions, if I recall correctly. Can someone correct me if I'm wrong?

I thought it was an awesome case btw! 👍👍👍

 

[EctopicFetus]

So we had this pt come in post-colonoscopy who actually had a syncopal event after the procedure. The GI attending called the ER and spoke to our attending and said that it was likely post-procedural vasovagal reaction but that the patient had to be evaluated... ok, no problem.

So the pt came down bradycardic to 40 but nothing on EKG and nothing on trop. The pressure began to drop a little to the 90s (sbp) and we began to think there was a bleed to this and that there was more than meets the eye.

The belly felt fine.... but on FAST, large fluid in Morrison's pouch!! CTap showed a large bleed. Hgb came back at 7 (from 13)!!

But the belly still felt benign... I recall my trauma attending telling me that it takes approx 6 hours for blood to cause peritonitis. Has this been your experience? Have you guys noted no peritoneal signs in a patient with blood in the belly (not to mention several liters of blood??)?

Bile can cause earlier peritoneal findings and so can gastric secretions, if I recall correctly. Can someone correct me if I'm wrong?

I thought it was an awesome case btw! 👍👍👍

Cool case.. Plenty of traumas have peritoneal signs with much less blood. Good case though. Very interesting.

 

[EM2BE]

So we had this pt come in post-colonoscopy who actually had a syncopal event after the procedure. The GI attending called the ER and spoke to our attending and said that it was likely post-procedural vasovagal reaction but that the patient had to be evaluated... ok, no problem.

So the pt came down bradycardic to 40 but nothing on EKG and nothing on trop. The pressure began to drop a little to the 90s (sbp) and we began to think there was a bleed to this and that there was more than meets the eye.

The belly felt fine.... but on FAST, large fluid in Morrison's pouch!! CTap showed a large bleed. Hgb came back at 7 (from 13)!!

But the belly still felt benign... I recall my trauma attending telling me that it takes approx 6 hours for blood to cause peritonitis. Has this been your experience? Have you guys noted no peritoneal signs in a patient with blood in the belly (not to mention several liters of blood??)?

Bile can cause earlier peritoneal findings and so can gastric secretions, if I recall correctly. Can someone correct me if I'm wrong?

I thought it was an awesome case btw! 👍👍👍

Thanks for sharing. It is an interesting case and will make me think of it next time if I end up having a similar pt come in.

 

[la gringa]

that's a county story for sure!

 

[Tiger26]

As a general rule, pretty much anyone who comes in with a complication/side effect of recent colonoscopy gets a CT--100% chance of something surgical

 

[Apollyon]

As a general rule, pretty much anyone who comes in with a complication/side effect of recent colonoscopy gets a CT--100% chance of something surgical

Not 100% - one of the last patients I saw on the mainland had a rectal sphincter spasm after colonoscopy and had a hugely dilated colon and pain, with the colon seen on plain film. As the rectal tube went in, there was a "sssssss", and his abdomen visibly deflated, like a balloon.

Also, "general rule/pretty much anyone" =/= 100%

 

[EM_Rebuilder]

Not 100% - one of the last patients I saw on the mainland had a rectal sphincter spasm after colonoscopy and had a hugely dilated colon and pain, with the colon seen on plain film. As the rectal tube went in, there was a "sssssss", and his abdomen visibly deflated, like a balloon.

Also, "general rule/pretty much anyone" =/= 100%

Just curious, was this one of your colleagues after the OPs patient came in?

Sorry, I couldn't resist..

 

[pinipig523]

Update:
So they're saying that the pt had a splenic laceration FROM the colonoscopy. They say that part of the splenic capsule is adhered to the colon at the splenic flexure and this may been disrupted during the colonoscopy!

I learn something new every day. Geez... who knew a simple colonoscopy would lead to a splenic lac!!

Scary....

 

[EM2BE]

Update:
So they're saying that the pt had a splenic laceration FROM the colonoscopy. They say that part of the splenic capsule is adhered to the colon at the splenic flexure and this may been disrupted during the colonoscopy!

I learn something new every day. Geez... who knew a simple colonoscopy would lead to a splenic lac!!

Scary....

Wow. I've heard of some complications occurring and most frequently at the flexures, but haven't seen it myself (yet).

 

[beanbean]

One of my colleagues had a case of splenic rupture from colonoscopy yesterday. Odd coincidence that you had one as well. They are fortunately not common but is it an important complication to be on the look out for.

 

[pinipig523]

One of my colleagues had a case of splenic rupture from colonoscopy yesterday. Odd coincidence that you had one as well. They are fortunately not common but is it an important complication to be on the look out for.

Weird... 😱

 

[Houser1121]

I worked a shift back in August, and had back to back patients with Abd pain s/p scope. One had a splenic lac, and the other perf'ed. Different GI guys too. Bad day for the surgeons.

 

[The White Coat Investor]

I had a ruptured spleen 10 days s/p colonoscopy. Picked it up on a CTA chest I got for an elevated d-dimer. Chief complaint was chest pain.

 

[Apollyon]

Had a pt signed out to me last night - mild abd pain 1d s/p colonoscopy. Afebrile, well-appearing. My boss was working the day shift - she was thinking of discharging the guy. The GI doc, though, wanted a CT. Sure. And, sure enough, free air at the splenic flexure. I mentioned this thread to a few people last night.

 

[pinipig523]

Don know about you guys, but from now on, I CT everyone post colonoscopy related complication.

 

[Rendar5]

This is a crazy thread. 2 nights ago, I had a patient 9 days out from colonoscopy with slight rebound throughout and generalized abd pain awaiting CT. i tell these stories to my attending, but scoff at the idea of a u/s being 9 days out. well, free fluid throughout the abd, 😱, though it ends up being a helluva hemorrhagic cyst.