P4652 - Between a Tumor and a Hard Place: Post-Colonoscopy Bowel Perforation in a Patient With Peritoneal Carcinomatosis

Tuesday, October 28, 2025

10:30 AM - 4:00 PM MT

Location: Exhibit Hall

Presenting Author(s)

AH

Anjali Herekar, MD

University of California Irvine Health
Irvine, CA

Anjali Herekar, MD¹, Shoujit Banerjee, MD², Christopher Soriano, MD³, Joshua Kwon, MD³, Nicholas Garcia, MD⁴, Nicholas N. Totah, MD⁴, Peter Nguyen, MD², Gregory Albers, MD, FACG³
1University of California Irvine Health, Irvine, CA; 2University of California Irvine, Orange, CA; 3University of California Irvine Digestive Health Institute, Orange, CA; 4University of California Irvine Health, Orange, CA

Introduction: Post-colonoscopy perforation is an uncommon occurrence, with an incidence of less than one per thousand for diagnostic colonoscopy1. The use of carbon dioxide insufflation rather than air is one of many strategies to reduce barotrauma and risk of perforation2. Both water immersion and carbon dioxide insufflation are generally considered safe3. This is a case of post-colonoscopy colon perforation after use of water immersion to proceed past a sigmoid stricture caused by extrinsic carcinomatosis.

Case Description/

Methods: A 49-year-old woman with history of invasive left lobular breast carcinoma and prior small bowel obstruction (SBO) presented with abdominal pain with imaging revealing a transition point in the terminal ileum and thickening of the terminal ileum and colon. A severe 8 mm stricture was noted in the sigmoid colon on prior flexible sigmoidoscopy. The patient underwent colonoscopy to rule out Crohn’s disease, which revealed a non-traversable stricture in the descending/sigmoid colon with lumen of approximately 2.5 mm at the narrowest point. Water immersion was used to open the lumen and advance past the stricture point but was unsuccessful. The patient then developed severe abdominal pain requiring emergency exploratory laparotomy. A transverse colon perforation was identified, and the patient underwent diverting loop ileostomy. There were findings of omental caking consistent with metastatic breast cancer. The patient was discharged after a prolonged recovery.

Discussion: Water immersion is often used to open the lumen and transverse strictures. However, in cases where the lumen is severely narrowed, water may not flow out of the stricture which causes air and fluid to be trapped in the proximal segment of the colon, creating a water seal. This patient had a transition point at the terminal ileum as well as sigmoid stricture, leaving the transverse colon susceptible to perforation if subjected to distension. In cases of stricture, carbon dioxide insufflation should be considered first to traverse the stricture, as the molecule absorbs quickly through the large bowel epithelium compared to water and thus carries a lower risk of bowel perforation.

References

1. Reumkens A et al. Am J Gastroenterol. 2016 Aug;111(8):1092-101.

2. Memon, Muhammed A et al. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 26(2):p 102-116, April 2016.

3. ASGE Standards of Practice Committee et al. Gastrointest Endosc. 2011 Oct;74(4):745-52.

Figure: Figure 1. Endoscopic view of sigmoid colon stricture.

Figure: Figure 2. Diagram of sigmoid colon stricture immediately post-colonoscopy and water immersion (left) and distension due to water seal (right).

Disclosures:
Anjali Herekar indicated no relevant financial relationships.
Shoujit Banerjee indicated no relevant financial relationships.
Christopher Soriano indicated no relevant financial relationships.
Joshua Kwon indicated no relevant financial relationships.
Nicholas Garcia indicated no relevant financial relationships.
Nicholas Totah indicated no relevant financial relationships.
Peter Nguyen indicated no relevant financial relationships.
Gregory Albers indicated no relevant financial relationships.

Anjali Herekar, MD¹, Shoujit Banerjee, MD², Christopher Soriano, MD³, Joshua Kwon, MD³, Nicholas Garcia, MD⁴, Nicholas N. Totah, MD⁴, Peter Nguyen, MD², Gregory Albers, MD, FACG³. P4652 - Between a Tumor and a Hard Place: Post-Colonoscopy Bowel Perforation in a Patient With Peritoneal Carcinomatosis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.