title: Endovascular treatment of active splenic bleeding after colonoscopy: a systematic review of the literature.
abstract: OBJECTIVE
  Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures.
  
  
  METHODS
  We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared.
  
  
  RESULTS
  All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8 %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74 %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44 %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST.
  
  
  CONCLUSIONS
  We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.
authors.affiliation: Département de Médecine Interne, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland, antonella.corcillo@chuv.ch.
authors.forename: Antonella
authors.initials: A
authors.lastname: Corcillo
authors.forename: Steve
authors.initials: S
authors.lastname: Aellen
authors.forename: Tobias
authors.initials: T
authors.lastname: Zingg
authors.forename: Pierre
authors.initials: P
authors.lastname: Bize
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.forename: Alban
authors.initials: A
authors.lastname: Denys
mesh_terms: D000368:Aged; D003113:Colonoscopy / Q000009:adverse effects*; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006465:Hemoperitoneum / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy; D006470:Hemorrhage / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D008297:Male; D012307:Risk Factors; D013154:Spleen / Q000000981:diagnostic imaging / Q000293:injuries*; D013157:Splenic Artery / Q000000981:diagnostic imaging / Q000293:injuries*; D014057:Tomography, X-Ray Computed / Q000379:methods