GI Endoscopy · 7 min read
Right-Colon Second Look: Retroflexion or Forward, Just Look Again
Haustra hide polyps on their proximal face. The fix is a second look at the right colon. Retroflexion is one way. Forward view is the other.
Hewett and Rex (2011) retroflexed the right colon after a careful forward exam in 1000 patients: success 94.4%, extra adenomas in 4.4% of patients, per-adenoma miss 9.8%, no perforations. Kushnir 2015 then randomized a second right-colon look to retroflexion versus forward view. Additional adenomas 7.5% versus 10.5%. Same job. The quality move is the second look, not a mandatory U-turn.
Experienced teaching points
Clinical Pearls
- Clear the right colon forward first. Then go back to the cecum and look again, retroflexed or forward.
- Hewett 2011: retroflexion success 94.4%. Failures were mostly looping, not a tight cecum.
- Kushnir 2015: second forward view matched retroflexion for extra adenomas. Low confidence in the first look is the strongest predictor to go back.
- This is not a polypectomy tutorial. Cold snare and SSL live on their own pages.
Clinical Bottom Line
| Question | Practical answer |
|---|---|
| Why look twice on the right? | The proximal faces of haustra and the hepatic flexure are blind on a single forward withdrawal. Interval right-colon cancer is the bill. |
| Must I retroflex? | No. Retroflexion works when it seats. A second forward withdrawal works as well (Kushnir 2015, PMID 25732415). |
| When is a second look most useful? | You already found a right-colon adenoma, you are not confident in the first pass, or the patient is older. Those were Kushnir's predictors. |
| When do I skip retroflexion? | Unstable position, looping you cannot reduce, a stiff right colon, recent right-colon surgery. Do the second look forward instead. |
| Is this how I remove polyps? | No. Detection page. Resection: CSP and UEMR. |
What did Hewett actually show?
Hewett and Rex (PMID 21679946) inspected cecum to hepatic flexure forward, removed what they saw, went back to the cecum, and withdrew in retroflexion. Success in 944 of 1000. Looping caused most failures. Forward view found 497 proximal adenomas. Retroflexion found 54 more. Per-adenoma miss 9.8%. Intention-to-treat miss at the patient level 4.4%. No adverse events. Older age, male sex, and polyps already seen forward predicted polyps in retroflexion.
They were careful about the claim. The yield looked like a second forward exam, not like a magic camera angle. That sentence is the whole later RCT.
Does retroflexion beat a second forward look?
Kushnir 2015 (PMID 25732415): 850 screening or surveillance colonoscopies, two centers. After a first right-colon withdrawal, randomization to a second look forward (n=400) or in retroflexion (n=450). Retroflexion success 93.5%. Overall ADR 46% versus 47%. Additional adenoma on the second look 10.5% forward versus 7.5% retroflexed (P=0.13). Predictors of a second-look adenoma: age, an adenoma on the first pass (OR 2.8), and low confidence in that first pass (OR 4.8). No adverse events.
So the unit of quality is "I looked at the right colon twice," not "I posted a retroflexed cecal photo." If retroflexion seats easily, use it. If it does not, withdraw forward again. Either beats a single casual withdrawal.
How do I do the maneuver?
Cecum confirmed. Right colon cleared forward. Reduce the loop. Reenter the cecum. For retroflexion: look for a roomy cecum or distal ascending, up-angle, torque, short movements. Inspect back toward the hepatic flexure. Come out of retroflexion before you jam the tip into a narrowed flexure. For forward: same reinsertion, slower withdrawal, more work on the proximal haustral faces, water to drop the folds.
Rectal retroflexion is a different, distal maneuver. Do not mix the photo sets. Pale right-colon lesions you find on either second look are often SSL. SSL page. Prep that makes the second look worth doing: BBPS.
Selected references
- Hewett DG, Rex DK. Miss rate of right-sided colon examination during colonoscopy defined by retroflexion. Gastrointest Endosc. 2011;74:246-252.
- Kushnir VM, et al. Impact of retroflexion vs second forward view examination of the right colon on adenoma detection. Am J Gastroenterol. 2015;110:415-422.
Last reviewed September 20, 2026. Written for clinicians who still withdraw the right colon once and hope the hepatic flexure was kind.
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