February 14th, 2011
Can colonoscopy cause diverticulitis?
Many of you out there have done many tens of thousands of colonoscopy like I have and are well aware of the complications most known to be associated with this procedure, like bleeding or perforation. And most of us are aware of very unusual complications that have been reported, such as splenic lacerations or barotraumas.
However, I recently had a patient develop acute diverticulitis within 24 hours of colonoscopy, and I have consulted in the last year on another patient who developed diverticulitis shortly after the procedure.
Although diverticulitis precipitated by colonoscopy prep or the procedure itself (microperforation from the bowel prep, pressure from the shaft of the instrument or air infused during the procedure, etc.) is plausible, there seems to be little in the literature on this subject.
One reason for the lack of data might be that there is not really an association, that these are two unrelated events. Another might be that because diverticulitis is not immediately evident (like bleeding or perforation), the causal link has been missed, given that delayed complications are not often reported in large series of procedures.
So I am asking you endoscopists out there:
1) Have you observed diverticulitis in a patient shortly after a colonoscopy?
2) Do you think the procedure can cause diverticulitis?
3) If so, what do you think the mechanism is for this complication?
I look forward to hearing from you.
80 Responses to “Can colonoscopy cause diverticulitis?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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I am a consultant colorectal surgeon, thus tend to see more of the complications that may not present immediately. In 6 years, I am aware of at least 2 cases where diverticulitis has followed colonoscopy. However, both were in cases of severe diverticulosis, where a neoplasia could not be ruled out on imaging. This is in a unit that performs over 6,000 colonoscopies a year, so I feel this complication must be considered in perspective. Both were in patients where IBS appeared to co-exist, as pain was a common symptom with bloating and loose stools, even theough there was no stricutre formation. To be sure the relationship truly exists, one would have to perform inflammatory markers as a minimum everytime a patients complains of post-procedure pain; and we know how non-specific that is! Considering the management of diverticulitis in the overwhelming majority of cases is conservative, the discussion may remain purely speculative, though one can easily guess the mechanisms, which would be similar to those of both conditions being induced mechanically.
Just had a case last week. Average risk screening colonoscopy. Had left sided diveticulosis. No polpys seen. No biopsies taken. 24 hours after the procedure developed fevrs, chills,left lower quadrant pain. AXR was normal. CT scan with possible diverticulitis. My first suspected case.
1)never
2)don’t know
3)don’t know
I HAVE NEVER HEARD IN THE LITERATURE ABOUT THIS.
I DONT THINK THAT YOUR ENDOSCOPE WAS A DIRECT CAUSE FOR THE ACUTE DIVERTICULITIS IN THIS PATIENT. WHAT I WOULD THINK THAT THIS PATIENT HAS HAD AN UNDIAGNOSED DIVERTICULAR DISEASE. BY SOMEHOW POST ENDOSCOPY HE HAD A FLARE OF HIS EXISTING DISEASE. YOU MIGHT WISH TO GO BACK AND REVIEW THIS PATIENT RADIOLOGY TO LOOK AT THE INTEGRITY OF HIS COLON BEFORE HAVING THE ENDOSCOPE.
I have had at least two patients develop diverticulitis within a few days after colonoscopy. In one case I suspected that the patient had mild or early diverticulitis at the time of the procedure, and that probably the mechanical trauma of the scope made it worse (edema? microperforation?). In the other case, I had no such suspicion. I have performed about 9000 colonoscopies over 20 years.
Dear Dr. Fennerty,
Some years ago when I was a consultant at a local GI unit I treated a female patient which developed a diverticulitis the day after an ambulatory colonoscopy in a nearby private practice.
We discussed damages and microbial invasion caused by air pressure (in a patient with a rectosigmoidal high pressure zone, as usual in diverticulosis) and mucosal tears caused by the manipulation as possible mechanisms.
The patient recovered quickly on antibiosis and was released on the third day.
But – to be honest – its the one and only case I remember in 16 years in GI Medicine (with 2 cases of splenic rupture) – so regarding the high incidence of diverticulosis, I don’t know, if there is really an association.
I also had a case of CT documented diverticulitis. The patient was a 60 year old female who was noted on her screening to have sigmoid diverticuli. There was no inflammation at the time and she had taken the Nulytly prep. She was admitted the day after the colonoscopy with abdominal pain. My initial concern was perforation but the procedure had been easy and I had not taken any biopsies. She did well but I also was surprised that the procedure seemed to have been responsible for her diverticulitis.
Brian: No cases of diverticulitis after over 15,000 colonoscopies, but some cases of LLQ pain in those with extensive sigmoid diverticula. Diverticular disease is likely inflammatory in origin with augmented neuromuscular hypersensitivity leading to increased colonic wall pressure forcing the formation of diverticula. Recent studies strongly suggest that reducing inflammation with low dose mesalamine in those who had hemorrhage or diverticulitis had a major reduction in subsequent episodes of either event. I have often noted that the diagnosis based solely on CT findings is very soft, so that some of the observations may be overstated. by the way, my website gut-check.com haas existed since 1997 and has a URL and a trade mark.
Having done colonoscopies in a small community for 34 years where I have been well aware of patient complications I have never seen diverticulitis develop following a colonoscopy. I have seen cases of undiagnosed diverticulitis at colonoscopy. I have found this inspite of seeing patients prior to all exams, suggesting that mild diverticulosis may not be highly symptomatic.
1) never. 2) yes 3)because microperforation by air insuflation
I am an Internist with “mild” diverticulosis. I developed diverticulitis 2 months after colonoscopy but in retrospect had been ill with GI complaints and maliase within 2 weeks of the procedure. Related? Maybe. Certainly there is mechanism that could be responsible-micro trauma. Are we missing mild cases that self resolve? I honestly have never thought there was an association before and the literature doesn’t indicate that there is.
In 3o years I don´t remember one case.
I am a general internist. I had one case of a patient developing liquid stools and abdominal pain 3 days after a colonoscopy done by a gastroenterologist. He presented to me because he was unsatisfied with the response of his gastroenterologist, who treated him with anti-diarrheals and spasmolytics. Rectal exam by me revealed tenderness and guaiac positive stool. Stool cultures were negative and abdominal x-ray was unrevealing. He responded rapidly to antibiotics. No other diagnostic information is available.
This board needs people, not doctors to tell you that a colonoscopy is responsible for many flareups of diverticulitis. I have never had problems with bowel movements or pain until 2 weeks after my first colonoscopy at 66 years old. Since then, for the past year I have not gotten back to normal with soft bowels, gas, and horrible bloating. I can’t eat a tablespoon of food without my stomach swelling to capacity. This was the worst test I have ever had and will never repeat it unless blood is coming out of my orifices. There is nothing I can do to get back to normal and I feel like I will suffer from this condition for the rest of my life. So sorry I ever had this done.
I performed a colonoscopy with polypectomy of a small rectal polyp 6 days ago on a 51 year old male with diffuse diverticulosis and remote appendectomy. He had no complaints until yesterday when he developed abdominal pain which today localized to the right abdomen. He moved slowly, but did not appear ill. Temp was nl. He had tenderness in the lateral right abdomen at the level of the umbilicus with some intermittent voluntary guarding. Cbc nl. APCT showed cecal and ascending colon wall thickening with inflammatory changes in the surrounding fatty tissue without free or localized extraluminal air. I suspect this is right sided diverticulitis. Remnant appendicitis is possible. A small perforation is possible, but I would have expected sxs sooner than 5 days. In any event I cannot rule out that I caused this problem. Any thoughts?
I am an internist who had her first colonoscopy today (age 51). After clear liquid diet for two days and a split dose of Suprep, I developed a slight fever 99.8 and no other symptoms. The test today revealed moderate diverticulosis in ascending, descending and sigmoid colon. I am home tonight with fever and chills and some boosting…maybe dome very very mild llq discomfort but not pain. No abdominal pain, bleeding or nausea. I am resting drinking cool water and have a heating pad on my tummy. If this gets worse, I will call my doctor or head back to the hospital.
I have seen a couple of cases where pt’s have had no diverticular disease seen at the time of colonoscopy only to be diagnosed with diverticulitis a short while later. (one was a few weeks later, one was a pt in their 30’s on a high fiber (almost vegetarian) diet who had an episode 2 years later. I have been wondering if the increased wall pressure from insufflation can cause diverticulosis. I don’t know of any literature on the subject, either.
I have never had a case of known diverticulitis following a colonoscopy in over 30 years of practice as a Gastroenterologist. But considering how many colonoscopies are now being done and the number of people with diverticular disease, I’m surprised it is not more common just by both things occuring at the same time. The association of colonoscopy and following diverticulitis may not be causal but only temporal. I have had at least 10 episodes of a procedure being cancelled because of consent problems or patient refusal and in the time period for the procedure or several hours later the patient had a MI, stroke, or other serious problem. Surely, if the procedure had been done, the MI or stroke would have been noted as a complication. Just because something happens just afterwards does not mean it is as a result of.
I am a registered nurse and have noticed two cases in which pt’s who had a colonoscopy (with results showing diverticulosis) ended up hospitalized for diverticulitis within a week. Question for you physicians is… would it be the physician’s technique?
I had a “routine” colonoscopy age 53 … a week later I was in the hospital with acute diverticulitis (low in the abdomin) I had 3 polyps removed during the colonoscopy and the report said that there was “NO” divericuli (divericitosis). This was about 3 months ago. I am starting to experience pain again (alittle higher up the abdomin) The pain is not as “intense” as before.
They did a CAT scan to determine the diverticulitis at the hospital. How can they differ from one another in one (1) week ?????