How to negotiate the splenic flexure during colonoscopy?

Negotiating the Splenic Flexure During Colonoscopy

The most effective technique for negotiating the splenic flexure during colonoscopy is to use a combination of variable stiffness colonoscope settings, patient positioning changes, and targeted abdominal pressure application. 1

Understanding the Challenge

The splenic flexure represents a common technical challenge during colonoscopy due to:

• Its acute angulation and fixed anatomical position 1
• Attachment to the spleen via the splenocolic ligament, creating tension during manipulation 2
• Risk of loop formation, which can cause patient discomfort and impede advancement 3

Recommended Techniques

1. Variable Stiffness Colonoscope Usage

• Activate maximum stiffness once the sigmoid colon has been negotiated and the colonoscope has been straightened with the tip in the proximal descending colon 1
• This reduces the number of ancillary maneuvers and shortens insertion time through the proximal colon 1
• The stiffening mechanism is most effective when used at the splenic flexure (71% of cases) 1

2. Patient Positioning

• Change patient position from left lateral to supine when approaching the splenic flexure 3
• This position change is successful in advancing the endoscope tip in approximately 68% of difficult cases 3
• Consider right lateral positioning in particularly challenging cases to provide better exposure of the left upper quadrant 4

3. Abdominal Pressure Application

• Apply external abdominal pressure to prevent loop formation 3
• Use a stepwise approach:
  • Begin with non-specific pressure to the region where looping is developing (more successful in left colon - 78% success rate) 3
  • Progress to endoscopically observed specific pressure near the tip if needed 3
• Most pressure applications need to last less than 30 seconds 3

4. Insufflation Management

• Use CO₂ insufflation rather than air to minimize bowel distension and patient discomfort 5
• Insufflate judiciously to avoid barotrauma 5

Risk Minimization

• Recognize when to abort the procedure if unusual difficulty is encountered in traversing the splenic flexure 5
• Be aware that splenic injury is a rare but serious complication (0.020-0.034% of procedures) with 30-day mortality of 3.6% 2
• Gentle progression and avoidance of excessive force can prevent complications 5

Technical Considerations

• Ensure adequate bowel preparation (at least 90% of patients should have excellent or adequate preparation) 5, 6
• Maintain minimum withdrawal time of 6 minutes (10 minutes aspirational) for thorough examination 5
• Follow appropriate sedation guidelines based on patient age 5

When to Seek Assistance

• If multiple attempts to negotiate the splenic flexure are unsuccessful despite using the techniques above 5
• When patient experiences significant pain despite appropriate sedation 5
• When loop formation persists despite abdominal pressure and position changes 3

By systematically applying these techniques, most colonoscopists can successfully navigate the splenic flexure while minimizing patient discomfort and risk of complications.