Colonoscopy is now the standard for colorectal cancer screening and study of colon diseases. Serious complications are rare in routine colonoscopies without a biopsy or polypectomy. We report a case of a 64-year-old woman with a history of a hysterectomy and heart valve replacement under warfarin therapy, who underwent colonoscopy because of rectal bleeding. Severe persisting abdominal pain and signs of shock were found after the procedure. An abdominal computed tomographic scan showed ascites. An emergency laparotomy was performed and revealed a serosal tear at the sigmoid colon with hemoperitoneum. A bleeding serosal tear is a rarely reported complication of colonoscopy. The risk of a bleeding serosal tear should be considered when performing a colonoscopy especially in high-risk patients with prior abdominal surgery and concurrent use of anticoagulants.