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Difficulty: HardGastrointestinal and Abdominal Surgery

A 74-year-old man with a history of Parkinson disease and severe chronic constipation is brought to the emergency department by his family due to a 2-day history of progressive abdominal distention, crampy lower abdominal pain, and obstipation. Vital signs are temperature 37.2°C (99.0°F), blood pressure 135/85 mm Hg, pulse 92/min, and respirations 16/min. Physical examination reveals a markedly distended, tympanitic abdomen. The abdomen is non-tender, with no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 11,000/mm³ and a normal serum lactate level. Arrange the following steps in the most appropriate chronological sequence for the standard definitive management of this patient's condition.

  1. 1Initial stabilization with intravenous crystalloids and electrolyte correction
  2. 2Diagnostic confirmation with cross-sectional abdominal imaging to rule out bowel ischemia
  3. 3Non-operative decompression via flexible sigmoidoscopy and rectal tube placement
  4. 4Mechanical bowel preparation and medical optimization
  5. 5Definitive surgical resection of the redundant colon with primary anastomosis

Answer

The correct sequence is: Initial stabilization -> Diagnostic confirmation with imaging -> Non-operative decompression via sigmoidoscopy -> Mechanical bowel preparation -> Definitive surgical resection.
The correct sequence prioritizes physiological stabilization first, confirms the diagnosis safely while ruling out surgical emergencies, attempts non-operative decompression to convert an emergency into an elective situation, prepares the patient, and finally provides definitive surgical cure to prevent recurrence.

Step-by-Step Solution

1
Assess hemodynamic stability and initiate fluid resuscitation.
The patient's intravascular volume is restored, preparing them for diagnostics and interventions.
Bowel obstruction causes third-spacing and dehydration, which must be addressed before or concurrent with further evaluation.
2
Obtain a CT scan of the abdomen and pelvis.
The classic 'coffee bean' sign is visualized, confirming uncomplicated sigmoid volvulus.
Cross-sectional imaging confirms the diagnosis and critically rules out perforation or ischemia, which would change the pathway to emergent laparotomy.
3
Perform endoscopic detorsion.
The volvulus is untwisted, passing a large amount of flatus and stool, decompressing the bowel.
Because the patient has no signs of peritonitis or ischemia (normal lactate, non-tender abdomen), endoscopic intervention is safe and avoids emergency surgery.
4
Perform mechanical bowel preparation.
The colon is cleansed of fecal burden.
Operating on an unprepared, obstructed bowel carries a high risk of anastomotic leak. Prepping the bowel allows for a safer primary anastomosis.
5
Perform elective sigmoid colectomy.
The redundant sigmoid colon is removed, and bowel continuity is restored.
Sigmoid volvulus has a high recurrence rate if managed with detorsion alone; resection during the same admission is the definitive standard of care.

Key Concept

The management of uncomplicated sigmoid volvulus requires endoscopic detorsion followed by elective definitive surgical resection during the same admission.
Estimated Time:1m 30s
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Topics

Gastrointestinal and Abdominal Surgery

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