San Antonio Uniformed Services Health Education Consortium Ft Sam Houston, TX, United States
Robert R. Byrne, MD, Charles B. Miller, MD, John P. Magulick, MD San Antonio Uniformed Services Health Education Consortium, Ft Sam Houston, TX
Introduction: Multiple anatomic factors contribute to incomplete colonoscopy such as diverticular disease, tortuosity and angulation, prior surgeries and adhesive disease. This case demonstrates the uncommon and unexpected challenge of intestinal nonrotation on successfully completing a colonoscopy.
Case Description/Methods: A 29 year old African-American male with sickle cell trait was referred for a colonoscopy for mild anemia and hematochezia. Extensive attempts to achieve deep cecal intubation were unsuccessful despite scope exchanges, water immersion technique, varying external abdominal pressure and position changes. An 8mm sessile polyp at the hepatic flexure was removed with cold snare and returned as a tubular adenoma, making procedure completion essential. Thorough review of the medical record revealed an abdominal CT performed four years prior during an ED evaluation for abdominal pain. The CT showed a large stool burden and malrotation of the gut with the colon entirely on the left side of the abdomen consistent with intestinal nonrotation. A repeat procedure with anesthesia support was performed. Planned to possibly require a balloon-assisted enteroscopy, the cecum and terminal ileum were successfully intubated with an enteroscope with affixed cap and a biopsy forceps in the channel to stiffen the scope. No additional polyps were noted and the hematochezia was attributed to internal hemorrhoids and a small anal fissure. He was recommended for a future surveillance procedure due to his confirmed tubular adenoma.
Discussion: This case highlights that intestinal nonrotation should be considered in the patient with an incomplete colonoscopy, especially without traditional risk factors for failure. Intestinal nonrotation is a congenital anomaly of the midgut causing complete failure of the second stage of rotation in the embryo resulting in the small intestine right of midline and the colon left of midline. The cecum may be found in the lower pelvis. The prevalence of intestinal rotation anomalies is 0.2%. Patients may be asymptomatic or present with chronic abdominal pain, obstruction, or volvulus and bowel ischemia requiring emergent surgery. Compared to other intestinal malrotation, nonrotation has low risk for volvulus and therefore more likely to present in adulthood. CT imaging or an upper GI series can be used for diagnosis. Preplanning with use of an enteroscope is an effective means to overcome the anatomical challenge of intestinal nonrotation.
Figure: CT Abdomen/Pelvis with IV contrast. The image demonstrates a coronal view of the patient's entire colon in the left hemiabdomen consistent with intestinal nonrotation.
Robert Byrne indicated no relevant financial relationships.
Charles Miller indicated no relevant financial relationships.
John Magulick indicated no relevant financial relationships.
Robert R. Byrne, MD, Charles B. Miller, MD, John P. Magulick, MD. P1486 - Twists and Turns: The Challenge of Colonoscopy in Intestinal Nonrotation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.