PICTURES IN DIGESTIVE PATHOLOGY

 

Importance of retroflexion in the rectum during colonoscopy

Importancia de la retroflexión en el recto durante la colonoscopia

 

 

J. García-Cano, C. Jimeno Ayllón, R. Martínez Fernández, L. Serrano Sánchez and A.K. Reyes Guevara

Department of Digestive Diseases. Hospital Virgen de la Luz. Cuenca, Spain

 

 

Case report

A 42-year-old male patient consulted several times for recurring episodes of bleeding per rectum. An anal source was clinically suspected from the beginning due to the pattern of blood expulsion after passing stools. The patient had been studied for this reason and had undergone two colonoscopies under deep sedation with propofol. Small size hemorroides were observed and different kinds of treatments were applied. As bleeding per rectum continued, the patient was referred to Surgery. In physical exam (anal inspection and anoscopy) the surgeon did not remark enough hemorroidal engorgement as to prescribe an operation. He ordered a third colonoscopy exam. In this occasion it was performed with the patient unsedated.

In this third procedure, with the endoscope in retroflexion in the rectum, a polyp with stalk was observed located a few centimetres above the pectinate anal line (Fig. 1). The examination continued until the cecal pole and no more lesions were found. Finally, snare polyp removal was performed (Figs. 2 and 3). No complications occurred.

 

Pathologic diagnosis was of a 1.7 cm of maximun diameter adenomatous polyp specimen with some foci of moderate dysplasia. Resection limit was clearly demarcated.

 

Discussion

Colonoscope retroflexion in the rectum is one of the basic manoeuvres in colonoscopy (1). Some lesions in the distal rectum and juxtanal zone can remain undiagnosed if retroflexion is not performed. This manoeuvre has to be done carefully because some perforations have been reported (2).

Besides, it is necessary to use other important techniques of colonoscopy, as the straitening of several bendings that form in the colon. Colonoscopy, in general, can be an uncomfortable procedure that usually requires some kind of sedation, nevertheless, experienced endoscopists using a careful technique, can perform successfully a large number of colonoscopies without sedation (3,4).

 

References

1. Vázquez Iglesias JL. Endoscopia digestiva: diagnóstica y terapéutica. 1^a ed. Madrid: Editorial Médica Panamericana; 2008.        [ Links ]

2. Quallick MR, Brown WR. Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center. Gastrointest Endosc 2009; 69: 960-3.        [ Links ]

3. Liao WC, Chiu HM, Chen CC, Lee YC, Wu MS, Lin JT, et al. A prospective evaluation of the feasibility of primary screening with unsedated colonoscopy. Gastrointest Endosc 2009; 70: 724-31.        [ Links ]

4. Petrini JL, Egan JV, Hahn WV. Unsedated colonoscopy: patient characteristics and satisfaction in a community-based endoscopy unit. Gastrointest Endosc 2009; 69: 567-72.        [ Links ]