title: Endoscopic cecal perforation: mechanisms of injury.
abstract: OBJECTIVE
  Most endoscopic perforations of the colon occur in the rectosigmoid area and are thought to be secondary to direct injury from the endoscopic instrument. The aim of this study was to describe the mechanisms of injury and clinical outcome of endoscopic perforation involving the cecum.
  
  
  METHODS
  Retrospective review of 6684 consecutive colonoscopic procedures performed at a university hospital over a 7-yr period.
  
  
  RESULTS
  Colonoscopy was complicated by perforation in 0.22%. Five of the 15 perforations occurred in the cecum. The mean age of these five patients was 79.6 +/- 17.7 yr (mean +/- SD). Indications for the procedure were bleeding (n = 4) and suspected obstructing cecal mass (n = 1). Abnormal endoscopic findings included diverticulosis, vascular malformations, cecal ulcer/inflammation, mass, and polyps. Perforation was directly attributable to an ancillary procedure (three routine biopsies, one electrocautery) in the cecal area in four patients, and cecal pathology (inflammation, ulceration) was a contributing risk factor in three patients. Mortality was 80%. In contrast, a noncecal perforation usually occurred at the sigmoid region and was associated with technical difficulties, e.g., inability to traverse a stricture or reach the cecum.
  
  
  CONCLUSIONS
  Routine forceps biopsy (without electrocautery) is an under-recognized cause of cecal perforation. Ancillary endoscopic interventions in the cecal region should be minimized in elderly patients with evidence of cecal inflammation. Pneumatic injury may be an additional risk factor for cecal perforation in patients with a colonic stricture or a tortuous colon.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Loma Linda University Medical Center, California 92354, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Foliente
authors.forename: A C
authors.initials: AC
authors.lastname: Chang
authors.forename: A I
authors.initials: AI
authors.lastname: Youssef
authors.forename: L J
authors.initials: LJ
authors.lastname: Ford
authors.forename: S C
authors.initials: SC
authors.lastname: Condon
authors.forename: Y K
authors.initials: YK
authors.lastname: Chen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000009:adverse effects; D016022:Case-Control Studies; D002432:Cecum / Q000293:injuries*; D012809:Colon, Sigmoid / Q000293:injuries; D003113:Colonoscopy / Q000009:adverse effects*; D004564:Electrocoagulation / Q000009:adverse effects; D005260:Female; D006801:Humans; D015994:Incidence; D007416:Intestinal Perforation / Q000209:etiology* / Q000401:mortality; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors