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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 11-December-2009, Vol 122 No 1307

Incarceration of an umbilical hernia following colonoscopy
Maxine M Beetham, M Imran Khan
Abstract
We describe the unique case of a patient who developed incarceration of a loop of small bowel in an umbilical hernia following an uneventful diagnostic colonoscopy. It was treated with laparotomy, with release of the incarcerated bowel and closure of the defect with nylon sutures.

Case report

A 72-year-old lady underwent a diagnostic colonoscopy for iron deficiency anaemia. Her background history included a small para-umbilical hernia which had been present for many years. The colonoscopy was a routine procedure carried out under intravenous sedation. The colonoscope was passed round to the caecum with some sigmoid looping but once through there, it passed easily into the caecum. A circumferential tumour was identified in the proximal transverse colon which was able to be negotiated and biopsied. She was discharged home post procedure but was readmitted the next morning with a history of abdominal pain and vomiting after her discharge from hospital. On examination she was afebrile with stable vital signs. Her abdomen was tender with guarding. The umbilical hernia was noted to be swollen, painful and irreducible. Bowel sounds were present. She had neutrophilic leucocytosis.
Pain abdominal X-rays showed distended loops of small bowels compatible with small bowel obstruction. Computerised tomography of the abdomen (Figure 1) showed a strangulated and obstructed loop of small bowel in the para-umbilical hernia.
Figure 1
The patient underwent laparotomy with release of the incarcerated, but viable loop of small bowel. The umbilical defect was closed with interrupted nylon sutures.
Biopsies taken at the time of colonoscopy confirmed adenocarcinoma of the colon. She later went forward for elective right hemicolectomy which was an uncomplicated procedure with an uneventful recovery.

Discussion

Colonoscopy is now accepted as the gold standard procedure for investigations of the colon.1 It’s safety profile has improved considerably overtime with advances in technology.2 However, as it is an invasive procedure, it carries a risk of complications. Bleeding and perforations rates vary widely in literature but are on average less than 0.3% to 0.1% respectively for diagnostic colonoscopy.3 The complication rates of therapeutic colonoscopy are about twice that of the diagnostic procedure.3
Rare complications include splenic injury, 4 the development of small bowel obstruction from internal hernia following a colonoscopy, 5 and incarceration of the scope in an inguinal hernia. 6
A literature search including MEDLINE and MESH showed no prior report of incarceration of small bowel in an umbilical hernia after colonoscopy, making this the only documented case of an incarcerated abdominal wall hernia reported post colonoscopy. It is unlikely to be a coincidence as the patient had the umbilical hernia for many years without any complications and her symptoms started soon after discharge from the hospital following the procedure.
The likely mechanism is perhaps an increase in intra-abdominal pressure following air distension of the colon during colonoscopy forcing the small bowel into the hernia and compromising its blood supply.
Author information: Maxine M Beetham, Surgical Registrar; M Imran Khan, Consultant Gastroenterologist; General Surgery, Tauranga Public Hospital, Tauranga
Acknowledgement: We thank Dr Janet Ansell (Consultant General Surgery, Tauranga Public Hospital) for her help.
Correspondence: Maxine M Beetham, Surgical Registrar, General Surgery, Tauranga Public Hospital, Cameron Road, Tauranga, Bay of Plenty, New Zealand. Email: Maxine.Beetham@bopdhb.govt.nz
References:
  1. MacRae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983;24:376-383.
  2. Viiala CH, Zimmerman M, Cullen DJ, Hoffman NE. Complication rates of colonoscopy in an Australian teaching hospital environment. Intern Med J 2003;33(8):355-359.
  3. Juillerat P, Peytremann-Bridevaux I, Vader JP, et al. Appropriateness of colonoscopy in Europe (EPAGE II). Presentation of methodology, general results, and analysis of complications. Endoscopy 2009;41:240-246.
  4. Di Lecce F, Vigano P, Pilati S, et al. Splenic rupture after colonoscopy. A case report and review of the literature. 2007 Sept-Oct;Vol 59(5):755-7 PMID.
  5. Patterson R, Klassen G. Small bowel obstruction from internal hernia as a complication of colonoscopy. Can J Gastroenterology 2000 December; Vol 14(11):959-960.
  6. Saunders MP. Colonoscope incarceration within an inguinal hernia: a cautionary tale. Br J Clin Pract 1995;49:157-158.
     
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