Behind the Ink: Unmasking Asymptomatic Micro-perforations Following Endoscopic Tattooing

Endoscopic tattooing is a valuable tool for identifying gastrointestinal lesions following initial discovery during endoscopy. Although generally considered safe, with minimal complications, routine post-procedure imaging is not practiced, and the detection of micro-perforation after tattooing is even rarer. We present a case of a 49-year-old male who underwent a colonoscopy for a workup of anemia, revealing a malignant-appearing mass in the ascending colon. The lesion was tattooed for further assessment. A follow-up CT scan for evaluation of metastatic disease incidentally demonstrated acute inflammatory changes and trace gas, consistent with micro-perforation. The patient was asymptomatic and hemodynamically stable on supportive treatment, with subsequent successful recovery. Therefore, close observation without additional interventions could be considered in patients with incidental micro-perforations and no symptoms. A large-scale study is needed to further demonstrate the correlation between endoscopic tattooing and micro-perforations to avoid unnecessary extensive evaluation.