A

            

                       

Abnormal right-sid

      

position ded sigmo

sig

of descenoid colon nificance

 

  

nding coland its cl

e

on with linical

ww.sciencedirect.com

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3

Available online at w

ScienceDirect

journal homepage: www.elsevier .com/locate/apme

Case Report

Abnormal position of descending colon withright-sided sigmoid colon and its clinicalsignificance

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

* Corresponding author.E-mail addresses: sajubinu@gmail.com, d

Please cite this article in press as: Cheriancolon and its clinical significance, Apollo

http://dx.doi.org/10.1016/j.apme.2014.07.0120976-0016/Copyright © 2014, Indraprastha M

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

rsajucherian_B@apolloim

SB, Gandhalam AJ, AbnMedicine (2014), http://

edical Corporation Ltd. A

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

sr.edu.in (S.B. Cherian).

ormal position of descending colon with right-sided sigmoiddx.doi.org/10.1016/j.apme.2014.07.012

ll rights reserved.

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 ) 1e32

Please cite this article in press as: Cherian SB, Gandhalam AJ, Abncolon and its clinical significance, Apollo Medicine (2014), http://

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

ormal position of descending colon with right-sided sigmoiddx.doi.org/10.1016/j.apme.2014.07.012

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3 3

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 inchildren: a problem-solving approach to the uppergastrointestinal series. Radiographics. 2006;26:1485e1500.

Please cite this article in press as: Cherian SB, Gandhalam AJ, Abncolon and its clinical significance, Apollo Medicine (2014), http://

2. Pyrtek LI, Jenney WL. Fixed retrocolic right sideddolichosigmoid colon. Ann Surg. 1960;151:268e273.

3. Kantor JL. Anomalies of the colon: their roentgen diagnosisand clinical significance resume of ten years’ study. Radiology.1934;23:651e662.

4. Fiorella DJ, Donnelly LF. Frequency of right lower quadrantposition of the sigmoid colon in infants and young children.Radiology. 2001;219:91e94.

5. Indrajit G, Sudeshna M, Subhra M. A redundant loop ofdescending colon and right-sided sigmoid colon. IJAV.2012;5:11e13.

6. Nayak SB, George BM, Mishra S. Abnormal length and positionof the sigmoid colon and its clinical significance. KUMJ.2012;10(40):95e97.

7. Chandrika GT, Gnanagurudasan. Right sided sigmoid colonearare case. Int J Biol Med Res. 2012;3(2):1842e1844.

8. Moore KL, Persaud TVN. The Developing Human. 8th ed.Saunders: Elsevier; 2009.

ormal position of descending colon with right-sided sigmoiddx.doi.org/10.1016/j.apme.2014.07.012

Apollo hospitals: http://www.apollohospitals.com/Twitter: https://twitter.com/HospitalsApolloYoutube: http://www.youtube.com/apollohospitalsindiaFacebook: http://www.facebook.com/TheApolloHospitalsSlideshare: http://www.slideshare.net/Apollo_HospitalsLinkedin: http://www.linkedin.com/company/apollo-hospitalsBlog:Blog: http://www.letstalkhealth.in/