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Colonoscopy perforation — ESEGH MCQ

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HardEndoscopyColonoscopy perforationESEGH

A 69-year-old woman develops worsening abdominal pain 4 hours after a difficult sigmoid colon polypectomy. Her pulse is 118 beats/min, temperature 38.2°C and blood pressure 102/64 mmHg. She has generalised guarding and rebound tenderness. CT demonstrates free intraperitoneal gas, pericolic fluid and extravasation of enteric contrast adjacent to the sigmoid colon. What is the most appropriate next step?

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Correct answer: E — Begin intravenous resuscitation and broad-spectrum antibiotics, keep her nil by mouth and obtain an urgent colorectal surgical review

The correct answer is E. This patient has a delayed colonoscopic perforation with an ongoing leak, systemic physiological disturbance and generalised peritonitis. She requires immediate nil-by-mouth management, intravenous fluid resuscitation, broad-spectrum antibiotics and urgent colorectal surgical assessment for operative source control. Endoscopic closure can be considered for selected early perforations in clinically stable patients with adequate bowel preparation and limited contamination, but repeat colonoscopy is inappropriate once generalised peritonitis and contrast extravasation are present. Conservative management is reserved for stable patients without deterioration or diffuse peritoneal signs. CT-guided drainage does not control a free ongoing colonic leak, and repeating CT would delay definitive treatment despite an already established diagnosis.

Reference: European Society of Gastrointestinal Endoscopy. Diagnosis and management of iatrogenic endoscopic perforations: ESGE Position Statement – Update 2020, colorectal treatment section. Endoscopy 2020;52:792–810. https://www.esge.com/assets/downloads/pdfs/guidelines/2020_a_1222_3191.pdf