Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance
 

Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance

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Variations in the disposition of colon are developmental in origin. Interruption of typical locations may lead to a variety of acute and chronic pathological conditions. Here we report an unusual case ...

Variations in the disposition of colon are developmental in origin. Interruption of typical locations may lead to a variety of acute and chronic pathological conditions. Here we report an unusual case of abnormal position of descending colon with right-sided sigmoid colon observed in a 70-year old male cadaver during the routine dissections for undergraduate medical students. In the present case, the descending colon crossed the vertebral column at L4 level to reach the right pelvic brim to continue as right sided sigmoid colon. Awareness of this finding is of crucial significance when performing procedures like percutaneous gastrotomy and radiologically guided entrostomy as it can lead to fatal sepsis in patients who undergo minimally invasive procedures.

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Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance Document Transcript

  • 1.                                                                                                   A                                      Abnormal right-sid        position ded sigmo sig of descen oid colon nificance      nding col and its cl e on with linical
  • 2. Case Report Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance Saju Binu Cherian* , Aruna Jyothi Gandhalam Department of Anatomy, Apollo Institute of Medical Sciences and Research, Jubilee Hills, Hyderabad 500096, India a r t i c l e i n f o Article history: Received 23 July 2014 Accepted 25 July 2014 Available online xxx Keywords: Large intestine Descending colon Sigmoid colon Pelvic colon Variation a b s t r a c t Variations in the disposition of colon are developmental in origin. Interruption of typical locations may lead to a variety of acute and chronic pathological conditions. Here we report an unusual case of abnormal position of descending colon with right-sided sigmoid colon observed in a 70-year old male cadaver during the routine dissections for undergraduate medical students. In the present case, the descending colon crossed the vertebral column at L4 level to reach the right pelvic brim to continue as right sided sigmoid colon. Awareness of this finding is of crucial significance when performing procedures like percutaneous gastrotomy and radiologically guided entrostomy as it can lead to fatal sepsis in patients who undergo minimally invasive procedures. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Malrotation of the intestine is a well defined congenital anomaly in which the intestines are abnormally placed in the peritoneal cavity and can involve the large and small intes- tine.1 The descending colon, a part of large intestine starts at the splenic flexure in the left hypochondrium and descends through the left lumbar and iliac regions to become contin- uous with the sigmoid colon at the medial margin of left psoas major infront of the left external iliac vessels. The sigmoid colon also called the pelvic colon begins at the left brim of true pelvis and descends in contact with the left pelvic wall and ends at rectosigmoid junction where it be- comes rectum at the level of third sacral vertebra. Sigmoid colon is suspended from the posterior pelvic wall by pelvic mesocolon. Literature survey reveals a vast number of reports with displacement of sigmoid colon towards right side associated with redundant loops of various parts of colon. In the present case, we report an unusual position of descending colon with right-sided sigmoid colon, its clinical implications and embryological basis which has not been reported earlier. 2. Case report During the routine dissections for medical undergraduates at Apollo Institute of Medical Sciences and Research, Hyderabad, an unusual position of descending colon with right sided * Corresponding author. E-mail addresses: sajubinu@gmail.com, drsajucherian_B@apolloimsr.edu.in (S.B. Cherian). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 Please cite this article in press as: Cherian SB, Gandhalam AJ, Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.07.012 http://dx.doi.org/10.1016/j.apme.2014.07.012 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  • 3. sigmoid colon was observed in a 70-year old thin and short statured female cadaver. The descending colon which measured about 31 cm started at the splenic flexure of left hypochondrium and crossed to the right side at the level of L4 level to reach the right iliac fossa to continue as the sigmoid colon at the right pelvic brim (Figs. 1 and 2). The pelvic colon measured about 6 cm long and began at the right pelvic brim to descend along the right side of sacrum to meet at rec- tosigmiod junction at the level of third sacral vertebra. The average lengths of ascending and transverse colon were 11 cm and 24 cm respectively which was shorter when compared to the normal. On observation, the descending colon also exhibited segmental narrowing of lumen or stric- ture along its length. The small intestine appeared to be normal and there were no signs of surgical removal of any parts of small intestine. The branches of inferior mesenteric artery supplied the sigmoid colon. 3. Discussion Variations in the length and disposition of colon are devel- opmental in origin and interruptions in various locations may lead to variety of acute and chronic pathological con- ditions.2 One of the variations reported is right-sided sigmoid colon. Elongation and displacement of sigmoid colon to the right side has been reported by Kantor in his radiological studies.3 Fiorella et al., in 1991 reported that the sigmoid colon is often normally positioned within the right lower quadrant in young children.4 In 2012, redundancy of loops of descending colon crossing the great vessels of abdomen with a right sided descending colon had been reported.5 In 2012, Nayak et al. reported an excessively long sigmoid colon with an inverted U shaped loop in front of descending colon and left kidney.6 In 2012, Chandrika et al. reported a case where the sigmoid colon began in the right iliac fossa and crossed the right pelvic brim and reached the left side of sacrum.7 The current case is unique as the descending colon crossed the midline at L4 level to the right with segmental narrowing of lumen accompanied with the short length of sigmoid colon on the right side. During the 10th week of intrauterine development, in- testines return back to the abdominal cavity after the physi- ologic midgut herniation. The small intestine returns first and occupies the central part of abdomen. As the large intestine returns, it undergoes a further 180-degree counterclockwise rotation to occupy the right side of abdomen.8 The current case remains unique because the descending colon crossed the midline at L4 level fusing with the left layer at root of mesentery and crossing abdominal aorta and inferior ven- acava. This course might have happened due to a secondary rotation of large intestine while the primary rotation was occurring in the small intestine. Or the primary position occupied by sigmoid colon in the lower right quadrant below the age of 5 years would have been retained in this case. A malpositioned sigmoid colon can pose problems for interventional radiologists and surgeons as it might lead to confusions in investigation, diagnosis and intervention. Presence of gas in the right sigmoid loop in a plain radiograph can cause problems during evaluation as it can be mistaken Fig. 1 e Disposition of descending colon (DC) with sigmoid colon. Note the abnormal crossing of descending colon and right sided sigmoid colon. Fig. 2 e Abnormal disposition of descending colon (DC) and sigmoid colon after the retraction of intestine. Arrow indicates the line of fusion of descending colon with left layer of root of mesentery. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32 Please cite this article in press as: Cherian SB, Gandhalam AJ, Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.07.012
  • 4. for cecal gas which is an important index for appendicitis and intussusception. Conscious awareness of this finding is important for clinicians while performing procedures like radiologically guided entrostomy and percutaneous cecostomies. Conflicts of interest All authors have none to declare. r e f e r e n c e s 1. Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006;26:1485e1500. 2. Pyrtek LI, Jenney WL. Fixed retrocolic right sided dolichosigmoid colon. Ann Surg. 1960;151:268e273. 3. Kantor JL. Anomalies of the colon: their roentgen diagnosis and clinical significance resume of ten years’ study. Radiology. 1934;23:651e662. 4. Fiorella DJ, Donnelly LF. Frequency of right lower quadrant position of the sigmoid colon in infants and young children. Radiology. 2001;219:91e94. 5. Indrajit G, Sudeshna M, Subhra M. A redundant loop of descending colon and right-sided sigmoid colon. IJAV. 2012;5:11e13. 6. Nayak SB, George BM, Mishra S. Abnormal length and position of the sigmoid colon and its clinical significance. KUMJ. 2012;10(40):95e97. 7. Chandrika GT, Gnanagurudasan. Right sided sigmoid colonea rare case. Int J Biol Med Res. 2012;3(2):1842e1844. 8. Moore KL, Persaud TVN. The Developing Human. 8th ed. Saunders: Elsevier; 2009. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3 Please cite this article in press as: Cherian SB, Gandhalam AJ, Abnormal position of descending colon with right-sided sigmoid colon and its clinical significance, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.07.012
  • 5. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/