Colonoscopy Risks

I just turned 50!  One of the many things I “look forward” to in my 50^th year is a routine colonoscopy that I’m sure my doctor will strongly recommend, if not insist I get.  Intellectually, I know that the benefits of colonoscopies FAR outweigh any risks, and that colonoscopies SAVE lives by detecting cancer and other potential health issues early enough to treat and eradicate before causing significant damage.

That said, our firm represents the families of three different people who LOST THEIR LIVES as a result of medical malpractice from a routine colonoscopy.  So, I’m a bit reluctant to consider the procedure “routine.”

Below are some of the colonoscopy risks based on cases that I have handled as well as knowledge of the procedure from being the lawyer in medical malpractice colonoscopy cases.

ATTORNEY DISCLAIMER:  I am not a doctor.  Below is neither medical nor legal advice.  Anyone considering a colonoscopy should discuss the risks and benefits with his or her medical professional.

 COLONOSCOPY RISKS

1.  Patient Stops Breathing Due To Anesthesia

The risk most likely to lead to the greatest harm, like loss of life or permanent brain injury, is that the patient will stop breathing due to delivered anesthesia.  In most cases, colonoscopy patients receive the same types of sedation and analgesic medication (like propofol and fentanyl) used for patients under general anesthesia but in reduced doses.  Under general anesthesia, the patient is completely sedated, so much so that the patient requires a breathing tube to assist with breathing and to keep oxygen flowing through the body.  With a breathing tube functioning properly, the patient should continue to receive sufficient oxygen irrespective of his/her ability to continue to breathe on his/her own, allowing the anesthesia team to deliver more sedation with drugs like propofol and fentanyl without causing harm.  As we’ve seen with the opioid crisis, the risk of using these drugs is that the user stops breathing.  This risk is mitigated under general anesthesia because the patient has a breathing tube ensuring a steady supply of oxygen.

The same anesthesia medication used for general anesthesia is delivered during a colonoscopy.  However, the amount delivered SHOULD NOT BE ENOUGH to cause the patient to stop breathing.  Anesthesiologists refer to what is delivered as “Monitored Anesthesia Care” or MAC and is commonly referred to as “twilight” or “conscious sedation.”  An anesthesia professional (not necessarily an Anesthesiologist – more later) must deliver the anesthesia (as opposed to the gastroenterologist performing the procedure), and the anesthesia professional must be in the room at all times during the procedure.  Patients receiving MAC are expected to continue breathing on their own.  Thus, unlike patients under general anesthesia, who are completely asleep and require a breathing tube, colonoscopy patients do not have a breathing tube.  Consequently, if a patient receiving a colonoscopy receives too much anesthesia, the patient may stop breathing, depriving the brain and body of oxygen.

A patient under MAC can also stop breathing if his/her airway becomes obstructed, which is a significant risk for patients with Sleep Apnea.  The most common form of Sleep Apnea occurs when the throat muscles relax so much during sleep that the airway becomes obstructed such that air can’t get to the lungs.  During normal sleep, the brain wakes a person up enough to rectify the obstruction, allowing air to get to the lungs and oxygen to the brain and body.  Thus, most untreated Sleep Apnea patients suffer from sleep deprivation, not oxygen deprivation.  However, with the aid of sedatives and opioids like propofol and fentanyl, a patient with Sleep Apnea under MAC may not wake up.  The patient may appear to be breathing, but air is not getting to the lungs nor oxygen to the blood due to an airway obstruction.  This condition is commonly referred to as “guppy breathing.”

This is what happened in two of my colonoscopy medical malpractice cases.  Both patients went for routine colonoscopies; one at an outpatient surgery center affiliated with his gastroenterologist, the other at a metro-Atlanta hospital.  Both patients were obese by medical definition; however, few people who saw them would say they were “fat.”  One had just been diagnosed with sleep apnea, which he appropriately disclosed to his gastroenterologist before the colonoscopy.  The other was identified as being at risk for sleep apnea by the anesthesia team on account of his weight but was not diagnosed with sleep apnea.

Both patients received quantities of propofol typically associated with general anesthesia as the anesthesia professional thought more was needed due to their weight and/or perceived arousal.  Both stopped breathing, likely because of an airway obstruction on account of sleep apnea.  In both cases, the anesthesia professional in the room did not notice the patient had stopped breathing timely.  Anesthesia professionals and, if performed in a hospital setting, nurses assisting them have medications at their disposal, such as atropine and epinephrine (both vasopressors), designed to increase pulse, blood pressure, and heart rate to get oxygenated blood circulating through the brain and body in the event of a suppressed breath rate.  Of course, these medications have to be delivered timely to have the desired effect.

Sadly, neither patient received timely intervention.  Both patients were eventually resuscitated.  Unfortunately, their brains were deprived of oxygen for too long, and both suffered irreversible anoxic brain injuries, making meaningful life impossible.  Both families opted for comfort measures once it was conclusively determined that neither would recover meaningful brain activity.  Both patients passed within two weeks of the colonoscopy procedure.  On behalf of their surviving spouses and children, The Baer Law Firm is pursuing medical malpractice cases against anesthesia providers and others involved for the wrongful death of these two men.

Facts Involving Surgery Center Patient – The patient with diagnosed sleep apnea had his procedure at an outpatient facility as opposed to a hospital.  Given his diagnosed sleep apnea, he probably wasn’t a suitable candidate to have the procedure at an outpatient facility.  The risk that he would stop breathing was too great not to have hospital resources readily available should something go wrong.  The anesthesiologist knew the patient had sleep apnea and was fully aware of the increased risk that he would stop breathing;  however, the anesthesiologist did not discover an issue until the patient’s face appeared “dusky,” i.e., had turned bluish-gray due to a lack of oxygen.

Facts Involving Hospital Patient – For the patient who had the procedure at a hospital, no one seemed to know how to reach the supervising anesthesiologist.  The law and most hospitals in Georgia allow mid-level providers, such as Nurse Anesthetists, to deliver anesthesia and monitor patients under anesthesia.  When delivering anesthesia, they are supposed to be “supervised” by an Anesthesiologist who has seen the patient and conferred with the Nurse Anesthetist regarding patient-specific risks and anesthesia plan.  However, in this case, the supervising anesthesiologist had not spoken with the nurse anesthetist delivering the anesthesia, much less the patient.  When the patient experienced a medical emergency, the nurses in the room did not have the supervising anesthesiologist’s phone number to reach him.

Thus, for the patient who had his colonoscopy performed at a hospital (which should be safer given the knowhow and manpower available to deliver emergency medical intervention immediately), there appears to have been at least a five-minute or longer delay between the time the nurse anesthetist realized the patient was in trouble and when atropine and epinephrine were delivered.  According to the nurse anesthetist, the hospital nurse in the room was confused as to what to do in the event of an emergency or how to initiate the hospital’s emergency response.  Hospitals have emergency response procedures often referred to as “Codes” of how to respond in the event of an emergency.  Failure to properly administer a code response can give rise to medical malpractice.  In this case, a Code Blue (when a patient stops breathing or suffers cardiac arrest) should have been initiated immediately.  Timely performance of Code Blue measures would have saved the patient’s life.

2. Procedure Causes Perforation or Bleeding

In performing a colonoscopy, a doctor inserts a large flexible tube (known as a colonoscope) with a camera on one end through the patient’s rectum and then moves this tube through the entirety of the colon.  The doctor may provide a flush of water to clean the colon.  In addition, the doctor will use surgical tools (introduced through the scope) to remove any polyps that are seen, provided they are small enough to be removed with forceps or other surgical tools.  A polyp is a small growth in the colon.  Most polyps are harmless but have the ability to become cancerous.  Because of this, doctors remove them and send them for testing to determine if they are precancerous.  This is the purpose of the colonoscopy – to identify and remove polyps and then test them to see if they show signs of cancer or precancer.

Any time foreign objects, like scopes and tubes, are inserted into the body and/or used to remove body tissue, there is a chance of perforation – a small tear in the lining of the colon — as well as bleeding.

Perforations – Perforations are rare, but when they occur, they require timely surgery to repair.  The colon is at the end of the digestive tract and contains mostly waste that is ultimately feces.  If it is allowed to escape the colon and enter the general body cavity, the bodily waste will likely cause a quick spreading infection – there is a reason pools, even heavily chlorinated pools, are immediately closed for cleaning when a child has an accident.

To determine whether a perforation has occurred, the doctor will primarily look for signs of free air in the abdominal cavity during the procedure and monitor post-procedure symptoms like severe abdominal pain, distention, fever, and tenderness.  If the physical exam is positive, the doctor may further confirm through imaging tests like an abdominal X-ray or CT scan to detect free air in the peritoneal cavity.

Perforations happen and usually do not give rise to a medical malpractice case.  Typically, medical malpractice occurs by failing to timely discover the perforation before life-altering or life-ending harm occurs.  I have handled cases that involved a delayed diagnosis of a perforation from other gastroenterology procedures.  In one case, a woman suffered severe septic shock followed by cardiac arrest and spent six months hospitalized as a result of a quick spreading infection following perforation of her stomach lining.  She ultimately made a fairly remarkable recovery, all things considered, but this should not have happened.  If the perforation had been addressed timely, she would have experienced minimal complications.

Bleeding – Bleeding is one of the more common risk factors associated with a colonoscopy but, in rare cases, can cause grave harm following the procedure.  In the overwhelming majority of cases where there is some bleeding, there is little actual harm.  The patient may notice his/her stool is darker due to blood, but the bleed eventually heals on its own.  However, in rare cases, the bleed is larger and may not heal on its own.  For example, if the patient is anemic.  Another more serious bleed can occur if the instruments used to perform a colonoscopy pull on other organs, such as the spleen, and cause a tear or rupture.  This is what happened in my third colonoscopy medical malpractice case.

The patient involved in this case went for a routine colonoscopy and suffered a serious bleed from a ruptured spleen following the procedure.  The doctor performing the colonoscopy is not to blame for causing the ruptured spleen.  The ruptured spleen was one of those rare complications that sometimes happens during the performance of the colonoscopy.  However, what happened next is clear medical malpractice in my view.

The patient was discharged and sent home following the colonoscopy.  It was no surprise there, as internal bleeds often do not present any symptoms for several hours.  The next day, the patient called 911 as she was nauseous and so weak she could not get out of bed.  She informed doctors and nurses in the emergency room that she had just had a colonoscopy the day before;  therefore, those caring for her should have considered that something during the colonoscopy could have caused the bleeding based on her presentation (nausea and weakness).  Further, blood tests showed low hemoglobin levels, which would have been another sign of internal bleeding.  A simple CT scan of her abdomen would have confirmed the laceration.

Unfortunately, a CT scan was not performed timely.  The patient remained in the emergency room for 12 hours as her pulse and blood pressure decreased, with no imaging to assess what was causing it.  Around midnight, she was transferred to the ICU with concern for septic shock.  At approximately 1:30 am, the hospital finally performs a CT scan, which shows a splenic rupture and bleeding as a result of the colonoscopy.  Once the bleeding was discovered, particularly given the 13-hour delay in assessing the bleed, she needed immediate surgery to stop the bleeding.  Incredibly, another 5 hours went by before anyone alerted the surgical team of her condition and the need for immediate surgical repair.  By the time she was taken into surgery, it was too late.  She lost too much blood, experienced acute hemorrhagic shock, and suffered cardiac arrest.  She passed due to incredible indifference from the providers tending to her.

3. Infection

Any surgery comes with the risk of infection.  No matter how sterile the people, rooms, and equipment are, bacteria exist.  Our skin prevents these bacteria from entering the body, and our pulmonary and digestive systems (from which we introduce outside air, food, and drink into our bodies) are closed systems containing microorganisms, acids, etc., to prevent entering bacteria from causing harm.  When you open the body up and introduce external tools into the body during surgery, you run the risk of infection.

Thus, like perforations and bleeding, infections occur from colonoscopy procedures IN THE ABSENCE OF ANY WRONGDOING.  Just because you or a loved one suffered a severe infection from being in the hospital or as a result of a medical procedure typically does not mean you have a viable cause of action for medical malpractice.  However, just like with perforations and bleeding, what gives rise to a case is when the infection is not timely discovered and/or treated, causing severe life-altering or life-ending harm.

 MITIGATING RISKS OF SERIOUS HARM DUE TO COLONOSCOPY

 To minimize risks, it is crucial to inform the Gastroenterologist of any and all health issues.  If you have sleep apnea, think it’s possible you have sleep apnea, or are at risk of sleep apnea (overweight, thick neck, smoke, family history of sleep apnea), let the doctor know.  Your gastroenterologist’s office should be asking A LOT of questions regarding sleep apnea beforehand.  Furthermore, if you are planning to have the colonoscopy at a private surgical facility as opposed to a hospital setting, ask if you are an appropriate candidate for an outpatient setting.

Of course, you should follow your healthcare provider’s instructions before and after the colonoscopy.  This includes adhering to dietary restrictions (typically no solid food after midnight and only clear liquids until six hours before start time) and consuming the laxative solution to cleanse the bowel beforehand.  It makes sense that a clean bowel makes it easier for the doctor to perform the procedure, which in turn can greatly reduce the risk of perforations or bleeding from the procedure.

If you experience severe discomfort, pain, nausea, weakness, or other symptoms that seem out of the ordinary for the procedure, DO NOT hesitate to seek medical attention.  Most infections, perforations, and bleeds resulting from a colonoscopy can be readily managed and serious harm can be prevented by receiving proper medical attention.  If at all possible, have a family member accompany you to the doctor or emergency room.  For reasons that are not clear to me, others, especially medical professionals, are inclined to take someone’s symptoms more seriously if they are corroborated by a loved one.

Patients should also engage in an open dialogue with their healthcare providers.  Discussing concerns, medical history, and any medications can help tailor the approach to individual risk profiles.

CONCLUSION

 In the realm of medical procedures, colonoscopies are safe.  The risk of serious injury and death is extremely small, especially compared to the benefits of early detection and prevention of cancer.  But colonoscopies are not risk-free.  The greatest risks are for those patients with sleep apnea, diagnosed and undiagnosed.

Early detection of any medical issue is key.  No one should lose their life as a result of a routine colonoscopy.  Anesthesia professionals need to monitor patients vigilantly, and they need to know how to initiate the emergency response properly.  Doctors need to thoroughly check for perforations before discharging patients.  Patients need to know the signs and symptoms of a perforation, internal bleeding, and infection so they can seek medical attention as soon as possible if experiencing such symptoms.

Bryan Baer

Attorney Bryan Baer has twenty (20) years of legal experience representing clients in serious and catastrophic personal injury and medical malpractice cases. He has been first chair in more than a dozen twelve-person jury trials on both the plaintiff and defense sides. Recognized as a leader in his legal community, he is frequently asked to speak at legal seminars on trial topics ranging from “Best Practices in Voire Dire” to “Maximizing Damages at Trial” as well as insurance issues such as “Navigating the Insurance Landscape” and “Injury Demands & Negotiations.” Learn more here.