Severe splenic injury following elective colonoscopy: case illustrations and practice-informed insights from published experience

INTRODUCTION: Splenic injury following colonoscopy is a rare but potentially life-threatening iatrogenic complication. Recognition is often delayed because symptoms are nonspecific, and evidence guiding management remains fragmented. METHODS: We report two contrasting contemporary cases, one managed successfully with splenic artery embolisation (SAE) and one requiring splenectomy for haemorrhagic control, illustrating the spectrum of clinical presentation and management. To contextualise these cases, we conducted a denominator-aware synthesis of 129 published cases meeting inclusion criteria. The mean patient age was 65.8 years (range 33-88), and 69.8% were female. Most patients (88.7%) presented within 24h of colonoscopy, although delayed cases occurred. Splenectomy was performed in 58.9% of cases, SAE in 10.1%, and conservative management in 33.3%, with an overall mortality of 5.5% among cases with reported outcomes. FINDINGS: Haemodynamic instability was strongly associated with operative treatment (odds ratio 9.11, 95% confidence interval 3.65-22.76), and splenectomy rates increased stepwise with higher computed tomography (CT) injury grades. Among haemodynamically stable patients, SAE was frequently definitive, avoiding splenectomy in all treated cases. These associations align with established trauma principles - management should be guided primarily by haemodynamic status. Early contrast-enhanced CT enables diagnosis and grading, while nonoperative management including SAE offers spleen-preserving control in stable patients. CONCLUSION: Splenic injury should be considered in any patient presenting after colonoscopy with abdominal pain, shoulder pain or haemodynamic disturbance. Early imaging, haemodynamic-based decision making, and appropriate follow-up can improve recognition, enable spleen preservation and reduce morbidity.