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.

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/