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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 77-year-old man is brought to the emergency department from a psychiatric group home with a 2-day history of worsening abdominal distension and an inability to pass flatus or stool. He has a medical history significant for schizophrenia and chronic severe constipation. His current medications include haloperidol, benztropine, and daily docusate. Vital signs reveal a blood pressure of 132/84 mmHg, a heart rate of 102/min, a respiratory rate of 16/min, and a temperature of 37.0°C (98.6°F). Physical examination demonstrates a massively distended, tympanic abdomen. There is generalized mild discomfort upon deep palpation, but no guarding, rigidity, or rebound tenderness is elicited. Digital rectal examination reveals an empty rectal vault without masses or gross blood.

Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and therapeutic management of this patient.

  1. 1Perform diagnostic imaging with an abdominal radiograph or CT scan.
  2. 2Attempt endoscopic detorsion using flexible sigmoidoscopy.
  3. 3Admit the patient for continued observation and bowel preparation.
  4. 4Perform a definitive semi-elective sigmoid colectomy.

Answer

The correct sequence is: 1) Diagnostic imaging with an abdominal radiograph or CT scan, 2) Attempt endoscopic detorsion using flexible sigmoidoscopy, 3) Admit the patient for continued observation and bowel preparation, and 4) Perform a definitive semi-elective sigmoid colectomy.
The patient presents with a classic clinical picture of sigmoid volvulus: an elderly, institutionalized individual with chronic severe constipation and psychiatric medication use presenting with progressive, massive abdominal distension. Because he is hemodynamically stable without signs of peritonitis (i.e., no guarding, rigidity, or rebound tenderness), the most appropriate initial step is diagnostic imaging (abdominal radiograph or CT) to confirm the diagnosis and rule out bowel perforation. Once confirmed and in the absence of free air, the first-line treatment is endoscopic detorsion and decompression via flexible sigmoidoscopy. Following a successful endoscopic reduction, the patient should be admitted for observation, resuscitation, and mechanical bowel preparation. Finally, because sigmoid volvulus recurs in up to 40% to 60% of cases if treated with detorsion alone, a definitive semi-elective sigmoid colectomy with primary anastomosis is indicated during the same hospitalization.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and perform a physical examination.
The patient is hemodynamically stable without signs of peritonitis, ruling out the immediate need for an emergent laparotomy.
To determine whether the patient is a candidate for endoscopic management versus emergent surgical exploration.
2
Obtain objective diagnostic imaging.
Order an abdominal radiograph or CT scan.
To confirm the clinical suspicion of sigmoid volvulus (e.g., identifying a 'coffee bean' sign) and to definitively exclude free intraperitoneal air.
3
Determine the initial therapeutic intervention.
Perform flexible sigmoidoscopy.
It serves as the first-line, minimally invasive treatment to decompress the bowel and untwist the volvulus in a stable patient.
4
Formulate a definitive long-term management plan.
Admit the patient for bowel preparation followed by a semi-elective sigmoid colectomy.
To prevent future episodes, as sigmoid volvulus has a high recurrence rate (40-60%) if treated with endoscopic detorsion alone.

Key Concept

Management sequence for uncomplicated sigmoid volvulus
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Topics

Gastrointestinal and Abdominal Surgery

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