How to Manage a Difficult Colonoscopy When Your Patient has a Redundant Colon
by Dr. Nimi Jayachandran, on September 27, 2021
Colonoscopies are one of the most effective tools for screening and diagnosing a number of colon and gut-related conditions. In the United States, doctors advise individuals aged 45 and over to get a colonoscopy to screen for colorectal cancers every 10 years, sometimes even more frequently. Individuals with any bowel discomfort or possible inflammatory bowel disease may also be advised to undergo a colonoscopy. While colonoscopies are routinely done in healthcare across the world and are generally considered to be relatively safe, in some individuals underlying conditions may cause difficult and potentially risky colonoscopies. One such condition which several radiologists, endoscopists, and surgeons alike have noted is the presence of a redundant colon. This is sometimes also called a tortuous or elongated colon and can lead to a difficult endoscopy.
The Role of the Colon in One's Health
The colon, also known as the large intestine, is an extremely significant part of the digestive system. It extends from the small intestine to the rectum and anus, containing bacteria which help to break down digested particles. One of the most important functions of the colon is to absorb water from undigested food and expel the remaining material into the rectum where it can be disposed of from the body as stool (fecal matter). In order for the digestive process to occur efficiently and effectively, good gut health is extremely important. A large part of this is ensuring that your colon is healthy. Your diet largely impacts your gut and colon health although genetic factors may also play a role. Experts advise including high-fiber foods in your diet to improve your bowel health. While fiber itself isn’t absorbed or digested by the body, including it in your diet will help improve your overall bowel health. It ensures healthy bowel movements, can prevent the risk of developing hemorrhoids, diverticular disease of the colon and even possibly reduce the risk of developing certain colorectal cancers.
What is a Redundant Colon?
Given the important role of the colon in maintaining and ensuring an individual’s overall health and well-being, it is important to understand what a redundant colon is. Anatomically, the colon is divided into four different parts: ascending, transverse, descending and sigmoid colon. The sigmoid colon is the part which connects to the rectum. On average, the colon is anywhere from 120 to 150 centimeters long (approximately 50 to 60 inches). However, in people with a redundant colon, the large intestine is abnormally long, particularly towards the descending colon area. Many times, this also results in additional looping or twisting of the colon and can give rise to further health problems. A tortuous colon and looping can also give rise to a difficult colonoscopy.
Challenges Associated with Redundant Colons
While some people with a redundant colon may never experience symptoms as a result of the condition, others may present with recurrent symptoms associated with it. Excessive bloating, constipation, and fecal impaction are often seen in the latter group of individuals. Fecal impaction occurs when the stool is dry and hard and unable to be passed via a bowel movement. As a result, there is a backing up of fecal matter in the colon. The symptoms of an elongated colon can cause complications on their own if not treated. Constipation can result in rectal prolapse, hemorrhoids, or even anal fissures. In addition to health risks arising from symptoms of a tortuous colon, individuals with this condition are at an increased risk of developing colonic volvulus, which is when the large intestine becomes twisted around itself. Many times colonic volvulus results in obstruction of the passage of stools and can become an emergency requiring surgical intervention.
In addition, a redundant colon also poses difficulties when undergoing a colonoscopy. In a colonoscopy, a long tube with a light at the end (called an endoscope or colonoscope) is passed through a person’s rectum and to their large intestine. The endoscope is able to bend so that the doctor can maneuver it around the colon’s natural curves and bends. The light and camera at the end of the endoscope allow the doctor to visualize the insides of the colon and determine if there are any reasons for concern. The scope also can blow air, should the doctor need to do so in order to better visualize any areas.
Redundant Colons and Difficult Colonoscopies
A difficult colonoscopy is one in which the endoscopist has a hard time passing the colonoscope through the entire colon or is unable to do so for a number of reasons. Redundant colons and a narrow or angulated sigmoid colon are two of the biggest causes of a difficult colonoscopy.
When a person has a tortuous colon, the additional length and looping can result in specific colonoscopy-related injuries or consequences. There are other factors that can contribute to a difficult colonoscopy. Women in general have longer colons than men, which is tightly packed into the abdominal cavity, and can result in several twists which can make maneuvering the endoscope difficult during the procedure. People with diverticular disease, a history of constipation, and those who reported using a laxative are also noted to have had a higher chance of having a difficult colonoscopy.
Prior to the start of the procedure, the patient is often given a mild sedative to ease the sensation of discomfort. The endoscopist and other staff in the room should take precautions to ensure that they are protected from possible body fluid, chemical or possible radiation exposure. The endoscopy staff must wear personal protective equipment (PPE) consisting of gloves, a disposable gown, protective eyewear, and a mask to cover the mouth, nose and oral mucous membranes. In case of a fluoroscopy, wherein a radioactive agent is used to better visualize specific regions of the colon, appropriate shielding must be provided to the staff. There should be a safe distance between the radiation beam and the endoscopy staff. Once all these measures have been taken, the cecal intubation can begin and the endoscopy can slowly be inserted.
Making Difficult Colonoscopies Easier
There are certain techniques that the endoscopist can familiarize themselves with in order to effectively maneuver a difficult colonoscopy. Some experts have found that applying manual abdominal pressure to the patient might help in preventing an increase in the stretching of the abdominal wall and can help the procedure go more smoothly. The American Society for Gastrointestinal Endoscopy (ASGE) has specified that this method should not be ignored and that its benefits have been recorded. In addition, repositioning the patient from left to right lateral or even having them lie in the prone position have been found to be effective tricks for endoscopists to maneuver a difficult colonoscopy procedure.
However in some instances, such as when handling colonoscopies for an obese patient or if the endoscopy staff lacks the strength or experience, these techniques may not work. In such instances, back-up methods have to be opted for to carry out the colonoscopy. Alternative endoscopes may be used; some are more flexible, others angled in particular ways, and may also vary in diameter to ensure that the procedure can be done. Products such as ColoWrap can also ensure that looping is reduced and the colonoscopy is made easy. ColoWrap is a compression device which the patient wears, it compresses their abdominal region and is designed to prevent looping by acting as a splint for the sigmoid and transverse colon. Not only does the device avoid the need for manual intervention and manipulation or repositioning of the patient, studies have shown that it reduces the cecal intubation time as well as reduce the need for patient sedation. Use of the device has also improved polyp and adenoma detection.
Posted by Dr. Nimi Jayachandran
Nimi Jayachandran was raised in the Bay Area and is a physician by profession. She attended a 6-year medical program in India after graduating high school, following which she worked in various healthcare settings in the country to better understand the healthcare infrastructure there. She has worked in Emergency & Trauma, Orthopedics, Womens’ Health Clinics, and Neurology. Out of interest she joined a 10-month journalism program and shortly after graduating took on a role of health correspondent with a digital media organization in Bangalore, India to apply her medical knowledge in a different way. She currently is based in the US and freelances as a medical writer and journalist.