Colonoscopy is widely accepted as the gold-standard screening technique for detecting malignancies in the distal gastrointestinal tract in patients with symptoms suggestive of colon cancer. However, this procedure is not without risk, including colonic perforation. We report a patient who was managed conservatively after colonoscopy induced perforation. Eighteen months after appearing to make a full recovery, he presented with an upper gastrointestinal bleed. Oesophago-gastro-duodenoscopy (OGD) revealed large gastric fundal varices and computed tomography (CT) revealed splenic vein thrombosis. The ensuing left-sided (sinistral) hypertension explains the development of the fundal varices in the presence of normal liver function. At surgery, a persistent abscess cavity was identified and cultures from this site grew Streptococcus anginosus. Curative splenectomy was performed and the patient made a full recovery. We advocate more prompt operative intervention in selected cases of iatrogenic colonic perforation with primary repair to prevent late complications. 1. Introduction A 69-year-old male presented with a one-week history of postural hypotension and melena. On physical examination, he appeared anemic, and a digital rectal examination confirmed melena. The examination was otherwise unremarkable, and there was no peripheral stigmata of chronic liver disease. Eighteen months previously he underwent a screening colonoscopy where diverticulosis and 8 polyps were snared, removed, and retrieved, varying in size between 5 and 25？mm. Histopathology confirmed benign tubular, tubulovillous adenomas, and adenomatous polyps. Following that procedure he developed a localized perforation in the area of the splenic flexure, with free air and abscess (Figure 1). This was treated conservatively, and he subsequently appeared to make a full recovery. Figure 1: Perforation showing free air in the peritoneum in the area of splenic flexure. Blood tests confirmed anemia (Hb 121？g/L, PLT 186 × 109？g/L), with normal liver function and prothrombin time. Assessment of his upper gastrointestinal bleed by oesophagogastroduodenoscopy (OGD) revealed large gastric fundal varices. Subsequent computed tomography (CT) of the abdomen with triple-phase contrast demonstrated a cluster of varices in the left upper quadrant (Figure 2). The splenic vein was thrombosed over a narrow segment between the tail of the pancreas and spleen. The ensuing left-sided (sinistral) portal hypertension explains the development of gastric varices in the presence of normal liver function. Since these varices
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