Woman Requires Colectomy After Botched Treatment of Polyp

Case Overview

This case involves an elderly woman who underwent a polypectomy. There was a target sign seen with deep cautery effect, and a decision was made to place several hemostatic clips. The patient was discharged the same day with no imaging modality performed. The next day, the patient awoke with increasing abdominal pain, elevated heart rate, and fever. She was admitted to the hospital with fecal peritonitis due to bowel perforation. She was given an open total abdominal colectomy as drainage of an intra-abdominal abscess.

Questions to the Internal Medicine expert and their responses

How often do you perform endoscopic polypectomy procedures?

I perform over 500 polypectomy procedures per year.

What is the clinical significance of finding a target sign on colonoscopy and what would be the appropriate management?

The 'Target Sign' is a descriptive term that suggests a possible breach of the colon's outer muscle layer with a heightened risk of perforation. To avoid the risk of resulting infections, such as sepsis and peritonitis, it is standard care to closely examine the polypectomy site post procedure. The examiner should look for 1) residual polyp tissue that may remain, 2) risk of bleeding at the polypectomy site and 3) risk of injury to the outer muscle layer. If a potential risk is recognized, it is customary to place clips to close the defect, if possible. Occasionally, the defect is so large that clips may not be sufficient to prevent a perforation.

When is follow up imaging ordered after a colonoscopy and when should a patient be admitted for observation after a colonoscopy?

Whether or not to admit the patient for observation and or obtain post-polypectomy imaging depends on the clinical concern of a perforation as well as the post-procedure recovery evaluation. Post-procedure, nursing staff must monitor several parameters-- including vital signs and pain level--to ensure the patient is safe and ready for discharge. If the Endoscopist is confident the defect has been successfully closed, it is proper to discharge the patient after an appropriate observation period. A review of the records is necessary to determine if sufficient evidence mandated overnight observation and or CT Imaging along with surgical consultation. Not all perforations require surgery. Some are managed by withholding food, antibiotics, and close monitoring.

About the expert

This expert has over 25 years of experience in the field of gastroenterology. He earned his BA in zoology from Rutgers University and his MD from the University of Texas Medical School. After completing an internship and residency in internal medicine as well as a fellowship in gastroenterology at the University of Texas, he went on to complete a second prestigious fellowship in advanced endoscopy at the Cleveland Clinic. Today, this expert is board certified in gastroenterology and is active in his field as a member of several professional organizations, including the American Gastroenterological Association and the American College of Gastroenterology. He also contributes heavily to research in his field with over 500 peer-reviewed publications and several book chapters. This expert previously was the clinical associate of gastroenterology for the Cleveland Clinic Foundation, the associate director of gastrointestinal endoscopy at Temple University, and a professor of gastroenterology at the University of Wisconsin. Currently, he is an attending physician at three medical centers and the director of the advanced gastroenterology program at a university-affiliated medical center. In addition, he is the medical director of the Bayshore Multispecialty clinic, a professor of gastroenterology, and the assistant division chief of gastroenterology at a medical school in Texas.