Hackensack Gastroenterology: Unexpected right colon mucosal bleeding on colonoscopy

The finding of hemorrhagic-appearing mucosa on colonoscopy is seen in a variety of conditions, including ischemia, inflammatory bowel disease, and infection.

1. In these cases, the presence of the endoscopic colitis is confirmed pathologically.
2. We have seen several cases in which patients with no symptoms to suggest colitis or bleeding had what appeared to be a hemorrhagic colitis in the right side of the colon on colonoscopy, but with normal tissue pathologically. We believe this to be a previously undescribed iatrogenic finding of the procedure.

Case 1

A 77-year-old woman was referred for evaluation of left lower quadrant pain. She had noted no change in her bowel habits or rectal bleeding. She had a colonic polyp removed 6 years before with no follow-up colonoscopy. She had a normal abdominal examination and guaiac-negative stool. Colonoscopy was performed. Rigidity and spasm of the colon and some looping of the endoscope were noted on insertion. There were numerous sigmoid diverticuli. On reaching the ascending colon, blood appeared to be streaking and coating the entire lumen of the ascending colon.

bleeding-case1

 

Case 2

An 81-year-old woman with a history of a low anterior resection for a sigmoid carcinoma in 1990 and a normal colonoscopy in 1991 underwent follow-up colonoscopy in 1992. On inserting the colonoscope, the mucosa appeared normal until the ascending colon was reached. In the ascending colon the mucosa appeared diffusely hemorrhagic.

bleeding-case2

 

Case 3

A 70-year-old man underwent colonoscopy because of a history of irregular bowel movements and two first-degree relatives with colon cancer. The examination was difficult because of a tortuous sigmoid, and numerous positional changes were needed to advance the endoscope. There were multiple sigmoid diverticuli. The mucosa appeared normal until the ascending colon was reached which, on insertion, appeared diffusely hemorrhagic with blood oozing from and coating the colonic wall. Biopsy results were normal. The patient has remained asymptomatic with 2 years of follow-up.

Case 4

A 75-year-old man underwent colonoscopy for evaluation of diarrhea. The examination was difficult with looping of the endoscope noted in the sigmoid colon. On reaching the ascending colon, what was described as a petechial hemorrhagic mucosal pattern was seen. Biopsy results were normal. One month later the diarrhea resolved. The patient has been asymptomatic for the past 5 years.

Case 5

A 60-year-old man with a family history of colon cancer and adenomatous polyps on a prior examination underwent follow-up colonoscopy. The patient had numerous sigmoid diverticuli and several positional changes were required to advance the endoscope. On reaching the cecum, blood was seen coating the mucosa and there appeared to be several small focal mucosal tears. An abdominal x-ray was performed right after the procedure and it showed a markedly distended cecum with minimal distension of the rest of the colon and small bowel. The patient was admitted to the hospital, kept NPO, and given intravenous antibiotics. Later that night, the patient developed a fever and leukocytosis. The patient, however, was afebrile the following day, was discharged home on hospital day six, and has had no further problems in 2 years of follow-up.

References

  1. Silverstein, FE, Tytgat, GNJ. in: Atlas of gastrointestinal endoscopy. 11. 2nd ed. JB Lippincott, Philadelphia; 1991:2–30.
  2. Ming, S, Goldman, H. Pathology of the gastrointestinal tract. in: WB Saunders, Philadelphia; 1992:230–233 (628-81, 697-709).
  3. Binmoeller, KF, Lieberman, DA. The watermelon cecum. Gastrointest Endosc. 1991;37:192–193.
  4. Silverstein, FE, Tytgat, GNJ. in: Atlas of gastrointestinal endoscopy. 1. 2nd ed. JB Lippincott, Philadelphia; 1991:26.
  5. Livstone, EM, Cohen, GM, Troncale, FJ, Touloukian, RJ. Diastatic serosal lacerations: an unrecognized complication of colonoscopy. Gastroenterology. 1974;67:1245–1247.
  6. Macrae, FA, Tan, KG, Williams, CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut. 1983;24:376–383.
  7. Luchette, FA, Doerr, RJ, Kelly, K et al, Colonoscopic impaction in left colon strictures resulting in right colon pneumatic perforation. Surg Endosc. 1992;6:273–276.

David M. Felig, MD, Myron H. Brand, MD, Ronald J. Vender, MD

Published in issue: Gastrointestinal Endoscopy, Volume 44, Issue 4, Pages 471–473,  October, 1996