Clinics and Research in Hepatology and Gastroenterology 46 (2022) 101975

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Case report

Colonoscopy induced ischemic colitis: An

endoscopic and histological assay
Abhishek Mahajan, Balaji Musunuri, Shiran Shetty∗

Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher
Education, Manipal, Karnataka, India

Available online 24 June 2022

KEYWORDS Abstract
Colonoscopy is a safe and effective diagnostic modality for various ileo-colonic diseases. Though
the procedure itself is a rare cause of ischaemic colitis. Fewer than 30 cases of ischaemic colitis
caused by colonoscopy procedure have been reported in the literature to date. The colon is
susceptible to ischemia due to its minor blood flow compared to other organs in the abdomen.
The etiology of colon ischemia after colonoscopy is multifactorial. Endoscopists must be aware
of this condition and its risk factors for risk minimization, early diagnosis and proper treatment.
© 2022 Elsevier Masson SAS. All rights reserved.

Introduction Case presentation

Colonoscopy can be used as a diagnostic and therapeutic
modality for various ileocolonic diseases. Colonoscopy is a
safe day-care procedure, but can also have procedure re-
lated adverse events, seen in 0.16–1.2% of patients, no-
tably perforation and hemorrhage [1]. These complications
are mainly seen when colonoscopy is used as a therapeu-
tic modality. Colitis following colonoscopy is extremely rare
and has only been described in patients with underlying
medical conditions such as connective tissue disease [2,3]
or historically in cases of anaphylaxis to agents used to dis-
infect colonoscopes [4]. Here, we describe a case in which
a patient developed ischemic colitis following diagnostic
colonoscopy.
∗ Corresponding author.
E-mail address: shiran.shetty@manipal.edu (S. Shetty).
68-year-old lady presented to our hospital with history
of constipation and non-specific abdominal pain for the
last 6 months. She was a known case of hypertension,
well-controlled with telmisartan and amlodipine. All lab-
oratory investigations done at admission were within the
normal range including hemoglobin, C-reactive protein,
and albumin. Because of elderly age, she was subjected
to colonoscopy for screening for colorectal cancer. Bowel
preparation was done with a split dose regimen of polyethy-
lene glycol. Colonoscopy revealed normal mucosal study
with no obvious ulcers, growth and erosions (Fig. 1).
Subsequently, on the following day of the procedure,
the patient started having loose stools mixed with blood
and lower abdominal severe intensity, colicky type of pain.
Her vitals were within normal range. On systemic examina-
tion, she was having tenderness in hypogastrium region. Be-
cause of these new symptoms and signs, blood panel was re-
peated, which showed leucocytosis (17,000/microliter) and
elevated C-reactive protein (66.6 mg/l). Along with blood

https://doi.org/10.1016/j.clinre.2022.101975
2210-7401/© 2022 Elsevier Masson SAS. All rights reserved.
 A. Mahajan, B. Musunuri and S. Shetty

Fig. 1 Normal initial colonoscopy. Fig. 1a-rectum, Fig. 1b-sigmoid colon.

Fig. 2 Changes in repeat sigmoidoscopy. 2a and 2b shows mucosal edema and haemorrhages in sigmoid colon.

investigations, stool analysis was also done to rule out in-

fectious causes and was negative for leucocytes and infec-
tions.
In view of persistent symptoms with raised inflamma-
tory markers, contrast-enhanced computed tomography ab-
domen was done to look for etiology and was unremark-
able. Hence, sigmoidoscopy was repeated after 36 h of on-
set of new symptoms. Sigmoidoscopy revealed patchy oede-
matous mucosa with erosions and submucosal haemorrhages
in sigmoid colon (Fig. 2) with normal rectum and descending
colon. Biopsies were taken for histopathological diagnosis.
Histopathological examination revealed mucosa with ex-
tensive edema and ulcerations within surface fibrin and neu-
trophilic debris along with focal areas of coagulative necro-
sis and muscle layer showing ischemic changes (Fig. 3). With
these findings, the diagnosis of active colitis due to ischemia
was made. Fig. 3 Histopathological features of ischemic colitis.
She was managed with intravenous fluids, analgesics and
antibiotics. Oral feeds were continued as tolerated. With
these measures, her symptoms started to improve and in-
flammatory markers came back to normal limits within 3 betes mellitus, peripheral vascular disease, chronic obstruc-
days. She was discharged on day 5 when her symptoms re- tive pulmonary disease, nephropathies, and atrial fibrilla-
solved. tion [5]. In our patient, there was no underlying cardiac dis-
ease or other risk factors and hypertension was well con-
trolled with medications. There was no hypotension dur-
Discussion ing the hospital stay including during first colonoscopy. Post
colonoscopy colitis has been described in various case re-
We here present a case of colitis probably due to is- ports earlier also [6]. The first case of ischemic colitis after
chemia following colonoscopy after polyethylene glycol colonoscopy was reported in 1990 [2]. Similar cases were
bowel preparation. also reported after colonoscopy which were secondary to
Major risk factors for colonic ischemia include age, hy- glutaraldehyde that was used for disinfecting scopes caus-
pertension, coronary artery disease, dyslipidaemia, dia- ing chemical colitis [4]. In our endoscopy suite, we use non-

2
 Clinics and Research in Hepatology and Gastroenterology 46 (2022) 101975

glutaraldehyde agent, ortho-phthalaldehyde 0.55% solution

for disinfecting scopes.
Multiple factors can lead to colitis after colonoscopy.
During colonoscopy, patients may experience excessive in-
testinal movements and spasms that can lead to vasocon-
striction, causing intestinal ischemia. Another factor can be
the usage of hyperosmotic laxatives for bowel preparation
[7], which can cause hypovolemia and decrease intravascu-
lar volume leading to increased intraluminal pressures and
hypoperfusion. Long procedure time and overinflation with
air during procedure, increases diameter of colon causing
increased colonic pressure which then leads to intestinal
ischemia [6]. Excessive intestinal traction during advance-
ment and retraction of the scope, at sharp bends or tor-
tuous colon, along with excessive gas, can induce localised
segmental intestinal ischemia [5,6].
This rare occurrence can be avoided by maintaining
adequate hydration during bowel preparation, avoiding
overinflation and using gentle manoeuvres especially at
bends/twists and in tortuous colon during procedure and us-
ing sedation in anxious patients.

Author contributions and article guarantor

A Mahajan wrote and revised the manuscript for intellectual
content. B Musunuri edited the manuscript and revised the
manuscript for intellectual content. S Shetty provided the
images, managed the patient and revised the manuscript
for intellectual content. All the authors approved the final
manuscript. S Shetty is the guarantor of the article.

Declaration of Competing Interest

The authors declare that they have no known competing fi-
nancial interests or personal relationships that could have
appeared to influence the work reported in this paper.

References
[1] Kothari ST, Huang RJ, Shaukat A, Agrawal D, Buxbaum JL, Abbas
Fehmi SM, et al. ASGE review of adverse events in colonoscopy.
Gastrointest Endosc 2019;90(6):863–76 e33.
[2] Wheeldon NM, Grundman MJ. Ischaemic colitis as a complica-
tion of colonoscopy. BMJ 1990;301(6760):1080–1.
[3] Versaci A, Macri A, Scuderi G, Bartolone S, Familiari L, Lupat-
telli T, et al. Ischemic colitis following colonoscopy in a sys-
temic lupus erythematosus patient: report of a case. Dis Colon
Rectum 2005;48(4):866–9.
[4] Ahishali E, Uygur-Bayramicli O, Dolapcioglu C, Dabak R,
Mengi A, Isik A, et al. Chemical colitis due to glutaralde-
hyde: case series and review of the literature. Dig Dis Sci
2009;54(12):2541–5.
[5] Maimone A, De Ceglie A, Siersema PD, Baron TH, Conio M. Colon
ischemia: a comprehensive review. Clin Res Hepatol Gastroen-
terol 2021;45(6):101592.
[6] Sadalla S, Lisotti A, Fuccio L, Fusaroli P. Colonoscopy-related
colonic ischemia. World J Gastroenterol 2021;27(42):7299–310.
[7] Oh JK, Meiselman M, Lataif LE. Ischemic colitis caused
by oral hyperosmotic saline laxatives. Gastrointest Endosc
1997;45(3):319–22.