perforation of the colon is a significant and well - recognized complication of fiberoptic colonoscopy . splenic rupture is even less common and a potentially life - threatening complication of colonoscopy . presentation can be delayed for hours or days after discharge and therefore not easily diagnosed without imaging . we report a case of diagnostic colonoscopy complicated by splenic injury and avulsion injury to right mesocolon in a patient , who was also found at surgery to have a cecal mass . the patient was a 76-year - old female who presented for an outpatient upper gastrointestinal endoscopy ( egd ) and a colonoscopy as a work - up for iron deficiency anaemia . she had a significant past medical history with coronary artery disease and previously underwent percutaneous coronary intervention with stents 4 years prior . suring colonoscopy , the bowel preparation was noted to be adequate but the colonoscopy procedure was noted to be technically difficult with looping experienced especially in the transverse colon and hepatic flexure . external manual pressure was also applied . repeated attempts to visualize beyond the hepatic flexure were unsuccessful , after which the procedure was aborted . one hour after the endoscopy , the patient complained of light - headedness when trying to get out of bed , with an episode of syncope . vital signs were notable for pulse of 110/min , blood pressure 110/70 mmhg , respiratory rate of 20/min . on physical examination , she appeared uncomfortable , diaphoretic and pale . laboratory work - up was remarkable for haemoglobin of 8.5 mg / dl ( preoperative hemoglobin was 9.5 mg / dl ) . given her prior history of coronary artery disease , she underwent an electrocardiogram and serum troponin levels were normal . a portable upright chest x - ray was found to be negative for pneumoperitoneum , effusions or infiltrates ( fig .  1 ) . figure  1:upright portable chest x - ray without evidence of pneumoperitoneum , effusions or infiltrates . she underwent immediate ct scan of the chest , abdomen , and pelvis with oral and intravenous contrast . during the preparation for the ct scan ct scan ( figs  2 and 3 ) revealed a large hematoma at the lateral margin of the spleen that displaced the spleen medially and compresses its lateral margin . a moderate amount of relatively low attenuation fluid also tracked into the right paracolic gutter and perihepatic space . there also appeared to be a 3.5  2.5 cm broad - based mass along the wall of the right colon . the ct scan of the chest also demonstrated a pulmonary embolus in a subsegmental artery of the right upper lobe . given these findings , the patient was aggressively resuscitated with packed red blood cells and taken emergently to the operating theatre . figure  2:oral and intravenous contrast enhanced ct of the abdomen demonstrating air within the colonic lumen and a 3.5  2.5 cm broad - based mass along the wall of the right colon ( white arrow ) . 
 figure  3:oral and intravenous contrast - enhanced ct of the abdomen demonstrating air within the colonic lumen and a large haematoma at the lateral margin of the spleen that displaced the spleen medially , compressing its lateral margin . a moderate amount of relatively low attenuation fluid is also seen tracking into the right paracolic gutter and perihepatic space . oral and intravenous contrast enhanced ct of the abdomen demonstrating air within the colonic lumen and a 3.5  2.5 cm broad - based mass along the wall of the right colon ( white arrow ) . oral and intravenous contrast - enhanced ct of the abdomen demonstrating air within the colonic lumen and a large haematoma at the lateral margin of the spleen that displaced the spleen medially , compressing its lateral margin . a moderate amount of relatively low attenuation fluid is also seen tracking into the right paracolic gutter and perihepatic space . at surgery , about 1.5 l of fresh blood and 1 l of blood clots were encountered with active bleeding around a shattered spleen . further exploration revealed a large hematoma around the hepatic flexure with avulsion of mesocolon causing visible evidence of ischaemia to the right colon . since the patient was haemodynamically unstable requiring massive blood transfusion , a primary anastomosis was avoided and an end ileostomy was performed with a mucus fistula . following this procedure , histological examination of the colon was remarkable for a 3 cm low - grade mucinous adenocarcinoma of the cecum . the patient made an uneventful recovery and was discharged home on the eighth postoperative day with plans to reverse the ileostomy in about 6 weeks . the most common complication associated with colonoscopy is colonic perforation ( 0.12.67% ) and haemorrhage ( 0.0012.5% ) , as described in multiple reviews of post - colonoscopy complications . . small perforations mostly result from direct mechanical trauma , such as the result of forceful passage of the tip of the endoscope through a diverticulum , inadvertent penetration of the side of a tight flexure or bend , or tearing during traversal of a narrowed stricture . the most common site of colonic injury is to the sigmoid colon followed by the cecum [ 3 , 4 ] . the most likely mechanism for this complication is tension on the splenocolic ligament , or from pre - existing adhesions , or both , due to manipulations of the sigmoid , descending colon , or transverse colon , or resulting passage of the endoscope through the splenic flexure resulting in parenchymal tears or avulsion of the spleen [ 6 , 7 ] . the use of aspirin and non - steroidal anti - inflammatory drugs has not been associated with an increased risk of bleeding after colonoscopy . splenic injuries after colonoscopy may be underreported and cases may remain undetected   and continue to remain a cause of concern . the diagnosis of splenic rupture may be delayed and could lead to a poor outcome . although computerized tomography is highly sensitive , suspecting this complication is the best way to assist in the early diagnosis . patients with abdominal pain , hypotension and a drop in haemoglobin without rectal bleeding after colonoscopy should be suspected of having splenic injury . the factors associated with splenic injury include difficulty intubating , looping of the instrument , traction on the splenocolic ligament , adhesions between the colon and spleen and the presence of a large polyp or mass at the splenic flexure . excessive external pressure on the left hypochondrium to facilitate scope passage can simulate blunt trauma .
diagnostic colonoscopy has evolved to become the gold standard for the screening for carcinoma and other diseases of the colon . 
 injuries to the colon are rare and may be managed in a variety of ways . 
 this includes observation and bowel rest or operative intervention and repair . 
 other organs are at risk during colonoscopy . 
 the present report describes a patient who underwent colonoscopy for the work - up of anaemia . following colonoscopy she developed signs of haemorrhagic shock and 
 was found to have haemoperitoneum . 
 she underwent surgery , and adenocarcinoma of the cecum was identified and managed during exploration . 
 the clinical management is described .