Dr.

Ahmed Nassr
Teaching assistant , General Surgery Dep.

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 A colonoscopy in which the endoscopist has
trouble getting through the entire colon or
fails to do so

SOURCE: Difficult Colonoscopy

Jerome D. Waye, MD 2
 longer-than expected procedure times
 incomplete procedures
 higher risks
 Incomplete colonoscopy rates vary from 4% to

25% and are associated with higher rates of

interval proximal colon cancer
 Unreliable results

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 Sex : females

 Age : younger

 Body habitus : obese , tall

 Previous abdominal surgery

 Inadequate bowel preparation

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 Ineffective sedation

 Diverticulosis

 Tortuosity

 Angulation or fixation of bowel loops

 Size and Malleability of the endoscope

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 Expertise of the operator

 Degree of training

 Operator fatigue

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 Sigmoid colon

 Hepatic flexure

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 Common sites : sigmoid and transverse colon

 signs of loop formation

 Types

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 sigmoid colon (80%)  10%

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 deep transverse  reverse α-loop ,5%
looping
 30%

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 reverse splenic  gamma-loop of the
flexure loop (3%, transverse colon
(1%),

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 reverse sigmoid spiral
 1%

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 Reduction of loops

 Changing positioning

 Abdominal pressure

 Real-time magnetic image-guided endoscopy

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 Adequate Bowel Preparation
- risk for inadequate bowel preparation,
including : patients with a history of
suboptimal bowel preparation, diabetes,
chronic constipation,or abdominal surgery, as
well as patients on medications that slow gut
motility (eg, tricyclic antidepressants,
opiates).

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 In such patients, a 2-day extended
preparation, with larger volumes of bowel
preparation, can be considered.
 Split-dose bowel preparation has shown to

have better colon cleansing in all segments of

the colon, and has recently become the
standard of care for colon cleansing

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 Monitored anesthesia care with propofol in
patients with factors of difficulty

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 Pediatric colonoscope or gastroscope

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 Nonspecific abdominal pressure
 Specific pressure near the tip of the

colonoscope

 position changes with the patient in a

stepwise manner

source: Polito et al 2005 26

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 water exchange
 water immersion

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 Carbon dioxide can be used for colonic
insufflation to prevent prolonged colonic
distention and discomfort

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 Magnetic Endoscope Imaging
 Overtube-Assisted Colonoscopy
 Double-Balloon Enteroscopy and Colonoscopy
 Single-Balloon Enteroscopy
 Integrated Inflated Balloon
 Spiral Overtubes
 Colon Capsule Endoscopy
 C-Scan Cap Imaging System
 Robotic Colonoscopes

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