hemorrhage and perforation are the most common complications after colonoscopy occurring in less than 1% of patients and often associated with biopsy or polypectomy . splenic injury or rupture is also an infrequent complication that is often forgotten and may require urgent surgical intervention . the first case of splenic trauma after colonoscopy was described by wherry and zehner in 1974 , but the true incidence of this dreadful complication is probably underestimated . there are 39 case reports in the english literature and at least 9 more in foreign publications ( table 1 ) . we report a similar case of splenic rupture diagnosed 18 hours after colonoscopy , which required emergent splenectomy . presentation , diagnosis , treatment , and potential risk factors are evaluated herein , as is a thorough review of the literature . summary of 42 cases of splenic injury after colonoscopy details were not provided in some cases . ct = computed tomography ; us = ultrasound ; acls = advanced cardiac life support . an 82-year - old woman was admitted to the hospital for mild congestive heart failure and pneumonia . her past history was significant for myocardial infarction and a left nephrectomy for transitional cell carcinoma via a left flank incision . after a week of intravenous antibiotics for left lower lobe pneumonia and bacteremia , she began having diarrhea . tests for clostridium difficile were negative , and the patient was diagnosed with antibiotic - associated diarrhea . during this period , her diarrhea became blood tinged , and her hemoglobin dropped by 3 g / dl . no acute origin of bleeding was identified , and findings included severe diverticulosis in the left colon and internal hemorrhoids . the postprocedure period was complicated by the onset of left upper quadrant abdominal pain accompanied by hypotension . laboratory tests revealed an acute drop in hemoglobin from 9.6 g / dl to 6.8 g / dl . the patient was transfused appropriately , and a computed tomographic scan ( ct ) of the abdomen and pelvis was ordered . the ct confirmed a large left upper quadrant hematoma , consistent with a splenic rupture and associated hemoperitoneum . the patient had persistent hypotension and acute anemia and therefore was taken to surgery for exploration . a midline laparotomy was performed , and a large amount of intraabdominal blood was encountered from the left upper quadrant . a moderate number of adhesions were present at the splenic flexure associated with a large splenic capsular tear . splenic injury after colonoscopy is a serious complication , yet its true incidence is unknown . numerous large series over the last 3 decades have demonstrated splenic trauma as a rare entity . reluctance to publish morbidity information , the absence of complication codes for splenic injury after colonoscopy , and the fact that the procedure is infrequently followed by routine surgical exploration all contribute to its unknown incidence . despite this uncommon complication , knowledge of this serious consequence is the best aide to early diagnosis because outcomes can be fatal . the cause of splenic complications after colonoscopy have not definitively been established , yet many risk factors have been proposed ( table 2 ) . the most common theory involves tension of the splenocolic ligament from either excessive manipulative traction or decreased mobility of the spleen or colon from adhesions . specific maneuvers like the slide by advancement , alpha maneuver , hooking the flexure , and straightening the sigmoid loop have all been implicated in excessive traction and splenic capsule avulsion . any prior surgery , inflammation , or intraabdominal infection may lead to adhesions and decreased mobility leaving the left upper quadrant susceptible to splenic insult during colonoscopy . it has been suggested that positioning the patient and minimizing external pressure may prevent splenic complications in higher risk cases . the left lateral position may allow the spleen and flexure to fall left and lax , preventing the tension of the spleen that occurs when it falls back in the supine position . despite precautions age does not appear to be a risk factor , because the age range for reported cases was 33 years to 90 years with a median age of 63 years . however , a higher risk of splenic complications does appear to exist in women . in reported cases that included gender , 72% ( 29/40 ) of cases occurred in women . it is unclear why there is a predominance of this complication in the female population ( table 3 ) . proposed risk factors for splenic injury during colonoscopy case characteristics of splenic injury after colonoscopy us = ultrasound ; ct = computed tomography ; acls = advanced cardiac life support . often early symptoms are attributed to postpolypectomy serositis , colonic distension , analgesia , sedation , old age , or impaired mental status . the differential diagnosis for significant pain within 24 hours after colonoscopy includes retained gas , perforation , and splenic injury . rare complications causing abdominal pain include mesenteric tears , volvulus and gas explosions . pain less than 12 hours postprocedure will warrant observation in most cases . in 39 patients with recorded symptoms , 31 ( 79% ) presented with the onset of symptoms in less than 24 hours . most patients present with abdominal pain , often in the left upper quadrant , that may radiate to the left shoulder . historically , kehr 's sign is pain at the tip of the left shoulder after bimanual palpation of the left upper quadrant with the patient in the trendelenburg position . it is not a reliable sign , and a positive kehr 's sign or left shoulder pain was only recorded in 55% ( 16/29 ) of patients . hypotension , anemia , or an elevated white blood cell count can also suggest a splenic injury . any patients with peritoneal signs or hemo - dynamic instability should be treated with a high index of suspicion for surgical perforation or splenic injury . although early onset of symptoms is common , delayed diagnosis even up to 10 days has been described as has a patient with serious splenic injury who was entirely asymptomatic . the diagnosis of a surgical abdomen should be made on clinical grounds , yet the advancement of imaging technology can elucidate the equivocal or suspicious case . a ct scan provides a definitive diagnosis and delineates the degree of injury that can often determine operative versus nonoperative management . ct was included in the diagnostic algorithm in 62% ( 25/42 ) of cases , and 11 of these scanned patients avoided a laparotomy and improved with nonoperative management . the use of ultrasound has been described in 5 cases , but 2 of these cases also included ct scans . ct remains the best diagnostic tool to aid in management , because all patients ( 11/11 ) treated nonoperatively were scanned in their evaluation . the goal of management in splenic injury after colonoscopy is nonoperative ; however , splenectomy may be difficult to avoid . thirty cases ( 70% ) required splenectomy , including half diagnosed by ct , but these numbers benefit from publication bias and the pre - ct era . janes suggested that predictors of failed conservative treatment include hemodynamic instability , underlying splenic disease , a grade iii traumatized spleen by ct , old age , and hemoperotineum . one case of splenic artery embolization has been reported , but the definitive interventional treatment remains splenectomy . two cases were diagnosed during emergent laparotomy , and one case was found during autopsy after the patient underwent severe shock . splenic injury and rupture are rare complications of colonoscopy that must not be forgotten in the differential for postprocedural pain . not using excessive maneuvers in high risk patients and having a high index of suspicion postprocedure will optimize outcomes .