Syncope as the Presenting Feature of Splenic Rupture after Colonoscopy

Splenic rupture is a rare, catastrophic complication of colonoscopy and an exceptional cause of syncope. This injury is believed to be from direct trauma or tension on the splenocolic ligament with subsequent capsule avulsion or else from direct instrument-induced splenic injury. Diagnosis requires a high index of suspicion that may be absent because presentation can be subtle, nonspecific, and delayed anywhere from hours to days and therefore not easily attributed to a recent endoscopy. We describe a case of syncope as the initial manifestation of splenic rupture after colonoscopy. Our patient’s pain was delayed; his discomfort was mild and not localized to the left upper quadrant. Clinicians should consider syncope, lightheadedness, and drop in hemoglobin in absence of rectal bleeding following a colonoscopy as possible warning signs of imminent or emergent splenic injury. 1. Introduction Splenic rupture is an exceptional and life-threatening complication of colonoscopy. At least 68 cases of splenic injury following colonoscopy have been documented as of 2009 [1]. Splenic rupture is in turn an unusual cause of syncope, so diagnosis requires a high index of suspicion that may be absent. Presentation can be nonspecific and delayed for days after outpatient discharge and therefore not easily attributed to a recent endoscopy. We describe a case of syncope secondary to splenic rupture after colonoscopy to alert clinicians to consider this rare event as a cause of syncope. 2. Case Report A healthy 63-year-old man underwent an uneventful screening colonoscopy without propofol sedation or procedural difficulty and was asymptomatic when discharged. Three hours later, he became lightheaded and diaphoretic with standing. He had a syncopal episode and hit his head against a wall. He lay down for several hours. When he sat up, lightheadedness and diaphoresis returned; he lost consciousness again. His wife witnessed and confirmed the episode. He was brought to the Emergency Department. He denied postictal confusion or bowel/bladder incontinence. He described mild, poorly localized abdominal discomfort following the second syncopal episode. His medications included amlodipine, simvastatin, and ranitidine for gastro-esophageal reflux. Blood pressure was 127/77？mm？Hg on admission without a postural change; the rest of the exam was unremarkable except for mild tenderness to palpation over the left trapezius, diminished bowel sounds, and mild tenderness to palpation in the left lower quadrant without signs of peritoneal irritation. He had a third syncopal event in the