International Journal of Colorectal Disease

, Volume 27, Issue 6, pp 811–816 | Cite as

Prevalence and risk factors for colonic perforation during colonoscopy in hospitalized end-stage renal disease patients on hemodialysis

  • Udayakumar Navaneethan
  • Sravanthi Parasa
  • Preethi G. K. Venkatesh
  • Bo Shen
Original Article


Background and aims

Colonic perforation is a rare complication during colonoscopy. A recent single center study reported a high incidence of colonic perforation in end-stage renal disease (ESRD) patients on hemodialysis (HD) who underwent colonoscopy. We sought to determine nationwide, population-based prevalence in rates of colonic perforation during colonoscopy among ESRD inpatients on HD in the US, and to assess risk factors for colonic perforation in this patient population.


We obtained patient data from the Nationwide Inpatient Sample and used the International Classification of Diseases, the 9th revision, clinical modification codes, to identify ESRD patients on HD who had undergone colonoscopy in 2006. The control group consisted of inpatients who had colonoscopy without ESRD.


Colonic perforations occurred in 51/17,000 ESRD hospitalizations on HD (0.3%) and 3,951/564,428 controls without ESRD (0.7%). The risk of colonic perforation among the study group was not significantly higher than the control group even after adjusting for patient demographics like age, gender and comorbid conditions (adjusted odds ratio [aOR] −0.55; 95% confidence interval [CI], 0.30–0.97). Older age (OR −1.007; 95% CI, 1.002–1.011) and female gender (OR −1.18; 95% CI, 1.03–1.36) were identified as independent risk factors for the risk of perforation in this population group.


There appeared no increased risk of colonic perforation during colonoscopy among inpatients who received HD in our study. Increasing age and female patients appeared to be associated with procedure-related colonic perforation.


Colonic perforation Colonoscopy End-stage renal disease Hemodialysis 



Charlson comorbidity index


End-stage renal disease




Healthcare cost and utilization project


Odds ratio


Nationwide inpatient sample


Conflict of interest

None of the authors declare any commercial conflict of interest.

Author contributions

Study concept, data monitoring, paper preparation and revisions—U. Navaneethan

Data monitoring and paper preparation—Preethi G.K. Venkatesh

Data monitoring and statistical analysis—Sravanthi Parasa

Study design, study concept and paper revisions—Bo Shen


  1. 1.
    Jemal A, Siegel R, Ward E et al (2008) Cancer statistics, 2008. CA Cancer J Clin 58:71–96PubMedCrossRefGoogle Scholar
  2. 2.
    Canadian Cancer Society/National Cancer Institute of Canada. Canadian cancer statistics 2008. Toronto, Canada, 2008Google Scholar
  3. 3.
    US Preventive Services Task Force (2002) Screening for colorectal cancer: recommendation and rationale. Ann Intern Med 137:129–131Google Scholar
  4. 4.
    Levin B, Lieberman DA, McFarland B et al (2008) Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570–1595PubMedCrossRefGoogle Scholar
  5. 5.
    Leddin D, Hunt R, Champion M et al (2004) Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: guidelines on colon cancer screening. Can J Gastroenterol 18:93–99PubMedGoogle Scholar
  6. 6.
    Fatima H, Rex DK (2007) Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 17:145–156, viiiPubMedCrossRefGoogle Scholar
  7. 7.
    Rex DK, Bond JH, Winawer S et al (2002) Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 97:1296–1308PubMedCrossRefGoogle Scholar
  8. 8.
    Arora G, Mannalithara A, Sinqh G et al (2009) Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 69(Suppl):654–664PubMedCrossRefGoogle Scholar
  9. 9.
    Rabeneck L, Paszat LF, Hilsden RJ et al (2008) Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 135:1899–1906PubMedCrossRefGoogle Scholar
  10. 10.
    Luning TH, Keemers-Gels ME, Barendregt WB et al (2007) Colonoscopic perforations: a review of 30,366 patients. Surg Endosc 21:994–997PubMedCrossRefGoogle Scholar
  11. 11.
    Iqbal CW, Chun YS, Farley DR (2005) Colonoscopic perforations: a retrospective review. J Gastrointest Surg 9:1229–1236PubMedCrossRefGoogle Scholar
  12. 12.
    Cobb WS, Heniford BT, Sigmon LB et al (2004) Colonoscopic perforations: incidence, management, and outcomes. Am Surg 70:750–758PubMedGoogle Scholar
  13. 13.
    Korman LY, Overholt BF, Box T et al (2003) Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 58:554–557PubMedCrossRefGoogle Scholar
  14. 14.
    Araghizadeh FY, Timmcke AE, Opelka FG et al (2001) Colonoscopic perforations. Dis Colon Rectum 44:713–716PubMedCrossRefGoogle Scholar
  15. 15.
    Levine JS, Ahnen DJ (2006) Clinical practice. Adenomatous polyps of the colon. N Engl J Med 355:2551–2557PubMedCrossRefGoogle Scholar
  16. 16.
    Davila RE, Rajan E, Baron TH et al (2006) ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc 63:546–557PubMedCrossRefGoogle Scholar
  17. 17.
    Holden RM, Harman GJ, Wang M et al (2008) Major bleeding in hemodialysis patients. Clin J Am Soc Nephrol 3:105–110PubMedCrossRefGoogle Scholar
  18. 18.
    Ajam M, Ramanujam LS, Gandhi VC et al (1990) Colon-cancer screening in dialysis patients. Artif Organs 14:95–97PubMedCrossRefGoogle Scholar
  19. 19.
    Imai N, Takeda K, Kuzuya T, et al. (2009) High incidence of colonic perforation during colonoscopy in hemodialysis patients with end-stage renal disease. Clin Gastroenterol Hepatol, Oct 3. [Epub ahead of print]Google Scholar
  20. 20.
    Levin TR, Zhao W, Conell C et al (2006) Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 145:880–886PubMedGoogle Scholar
  21. 21.
    Naidu SS, Selzer F, Jacobs A et al (2003) Renal insufficiency is an independent predictor of mortality after percutaneous coronary intervention. Am J Cardiol 92:1160–1164PubMedCrossRefGoogle Scholar
  22. 22.
    Toh Y, Yano K, Takesue F et al (1998) Abdominal surgery for patients on maintenance hemodialysis. Surg Today 28:268–272PubMedCrossRefGoogle Scholar
  23. 23.
    Whalen D, Houchens R, Elixhauser A (2002) HCUP Nationwide Inpatient Sample (NIS) comparison report. U.S. Agency for Healthcare Research and Quality 2005 Jun 24. Report No.: 2005–03, pp 1–89Google Scholar
  24. 24.
    Quan H, Parsons GA, Ghali WA (2002) Validity of information on comorbidity derived from ICD-9-CCM administrative data. Med Care 40:675–685PubMedCrossRefGoogle Scholar
  25. 25.
    Gatto NM, Frucht H, Sundararajan V et al (2003) Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Canc Inst 95:230–236CrossRefGoogle Scholar
  26. 26.
    Gomes OA, de Souza RR, Liberti EA (1997) A preliminary investigation of the effects of aging on the nerve cell number in the myenteric ganglia of the human colon. Gerontology 43:210–217PubMedCrossRefGoogle Scholar
  27. 27.
    Hanani M, Fellig Y, Udassin R, Freund HR (2004) Age-related changes in the morphology of the myenteric plexus of the human colon. Auton Neurosci 113:71–78PubMedCrossRefGoogle Scholar
  28. 28.
    Anderson ML, Pasha TM, Leighton JA (2000) Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol 95:3418–3422PubMedCrossRefGoogle Scholar
  29. 29.
    Saunders BP, Fukumoto M, Halligan S et al (1996) Why is colonoscopy more difficult in women? Gastrointest Endosc 43(2 Pt 1):124–126PubMedCrossRefGoogle Scholar
  30. 30.
    Yasuda K, Tahara K, Kume M et al (2007) Risk factor for morbidity and mortality following abdominal surgery in patients on maintenance hemodialysis. Hepatogastroenterology 54:2282–2284PubMedGoogle Scholar
  31. 31.
    Goodkin DA, Bragg-Gresham JL, Koenig KG et al (2003) Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). J Am Soc Nephrol 14:3270–3277PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Udayakumar Navaneethan
    • 1
  • Sravanthi Parasa
    • 2
  • Preethi G. K. Venkatesh
    • 1
  • Bo Shen
    • 1
  1. 1.Digestive disease Institute, Cleveland Clinic FoundationClevelandUSA
  2. 2.Department of EpidemiologyUniversity of WashingtonSeattleUSA

Personalised recommendations