What is the best course of management for a patient with persistent right-sided abdominal pain following colonoscopic polypectomy?

Management of Post-Colonoscopic Polypectomy Right-Sided Abdominal Pain

This patient most likely has post-polypectomy syndrome (PPS), a benign transmural burn that mimics perforation but resolves with conservative management alone—continue watchful waiting with bowel rest, analgesia, and return precautions, avoiding unnecessary imaging or surgical intervention at this stage. 1, 2

Clinical Reasoning and Diagnosis

The presentation 3-4 weeks post-polypectomy with right iliac fossa tenderness, pulling sensation, and absence of fever (36.6°C), rebound tenderness, or systemic signs strongly suggests post-polypectomy syndrome rather than perforation or other surgical emergency 1, 2. Key distinguishing features include:

• Timing: PPS typically presents within hours to days post-procedure, but localized inflammation can persist for weeks 1, 3
• Examination findings: Soft abdomen with localized tenderness but no peritoneal signs, normal temperature, and present bowel sounds effectively rule out acute perforation or peritonitis 1, 2
• Pain characteristics: The "pulling" sensation and positional nature (worse when rolling onto right side) suggest localized serosal irritation or muscular strain rather than intra-abdominal catastrophe 1

The large polyp size (33mm) increases risk of transmural thermal injury during electrocoagulation, which irritates the serous membrane and causes localized peritoneal inflammation without actual perforation 1, 2, 3.

Immediate Management Algorithm

Current approach is appropriate—no additional intervention needed at this time:

• Continue analgesia (strong painkillers already helping) 4
• Maintain normal diet unless symptoms worsen (patient tolerating food) 1
• Avoid NSAIDs if possible given HIV status and potential medication interactions 4
• No antibiotics indicated (afebrile, no systemic signs) 1, 2

Red Flags Requiring Urgent Reassessment

Instruct patient to return immediately if any of the following develop:

• Fever >38°C, rigors, or worsening systemic symptoms 1, 2
• Development of peritoneal signs (guarding, rebound tenderness, rigid abdomen) 1, 2
• Severe unremitting pain unresponsive to analgesia 5, 6
• Inability to tolerate oral intake, persistent vomiting 5
• Signs of obstruction (absence of flatus, no bowel movements, progressive distension) 5, 6
• Hemodynamic instability (tachycardia, hypotension) 6

If any red flags develop, obtain CT abdomen/pelvis with IV contrast (90% accuracy for complications) to evaluate for delayed perforation, abscess, or bowel ischemia 5, 6.

Physiotherapy Referral Timing

Defer physiotherapy for 2-3 weeks minimum:

• The "muscular" quality of pain may reflect abdominal wall strain from positioning during colonoscopy, but underlying serosal inflammation must resolve first 1, 3
• Premature mobilization exercises could exacerbate transmural inflammation 1
• Reassess in 2 weeks; if pain persists beyond 6 weeks post-procedure without red flags, then consider physiotherapy 1, 3

Work Considerations

The phased return approach with fit note until 26/12/2025 is appropriate given:

• Physically demanding occupation (street cleaner/HGV driver) requires full recovery 1
• Increased flatulence and positional pain would impair job performance 1
• Risk of exacerbating transmural burn with heavy lifting or prolonged sitting 1, 3

Common Pitfalls to Avoid

Do not order unnecessary imaging: CT scan is not indicated in stable patients with benign examination findings, as it exposes to radiation and may show expected post-procedural changes (wall thickening) that prompt unnecessary intervention 1, 2.

Do not prescribe antibiotics empirically: PPS is sterile inflammation; antibiotics are only indicated if perforation or abscess is confirmed 1, 2, 3.

Do not assume surgical emergency: The key distinction is that PPS mimics perforation clinically but follows a benign course—surgery is contraindicated and potentially harmful 1, 2.

Recognize delayed perforation is rare but possible: While most perforations present within 24 hours, delayed presentation up to 5-7 days can occur, though 3-4 weeks makes this extremely unlikely 3, 7.

HIV-Specific Considerations

Medication interactions require attention:

• Avoid NSAIDs if on tenofovir (renal toxicity) or ritonavir-boosted regimens (GI bleeding risk) 4
• Opioid metabolism may be affected by protease inhibitors or NNRTIs—adjust doses accordingly 4
• Ensure adequate pain control without compromising antiretroviral adherence 4