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Difficulty: MediumGastrointestinal and Abdominal Surgery

An 81-year-old man who resides in an assisted living facility is brought to the emergency department after 3 days of progressive abdominal swelling, obstipation, and bilious emesis. He has a medical history of severe Parkinson disease, hypertension, and chronic constipation. On arrival, his temperature is 38.8°C (101.8°F), blood pressure is 82/50 mmHg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended, tympanitic abdomen with diffuse rebound tenderness and involuntary guarding. Laboratory evaluation demonstrates a leukocyte count of 21,000/mm³ and a serum lactate level of 6.1 mmol/L. Following initial intravenous fluid resuscitation, a portable abdominal radiograph is acquired, demonstrating a massive, dilated, inverted U-shaped colonic loop arising from the pelvis and projecting toward the right upper quadrant. There is no pneumoperitoneum visible. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Flexible sigmoidoscopy with placement of a decompression tube
  3. C
    Computed tomography of the abdomen and pelvis with intravenous contrast
  4. D
    Nasogastric tube decompression and serial abdominal examinations
  5. E
    Fluoroscopy-guided water-soluble contrast enema

Answer

Immediate exploratory laparotomy is the most appropriate next step for a patient with a sigmoid volvulus who exhibits signs of bowel strangulation (peritonitis, hemodynamic instability, lactic acidosis).
The patient's clinical presentation is classic for a sigmoid volvulus, characterized by chronic constipation, massive distension, and an inverted U-shaped loop (coffee bean sign) on an abdominal radiograph. While uncomplicated sigmoid volvulus is typically managed first with flexible sigmoidoscopy and placement of a decompression tube, this approach is contraindicated if there is evidence of bowel compromise. This patient exhibits clear signs of bowel strangulation and ischemia, including fever, hemodynamic instability (hypotension, marked tachycardia), elevated serum lactate, and diffuse peritonitis (rebound tenderness, involuntary guarding). In this setting, the bowel is likely gangrenous or already micro-perforated. Attempting endoscopic decompression or further diagnostic imaging would delay life-saving treatment and increase the risk of massive fecal spillage. Therefore, the most appropriate next step is immediate exploratory laparotomy to resect the nonviable segment of the colon and achieve source control.

Step-by-Step Solution

1
Identify the primary diagnosis from the clinical presentation and imaging.
The patient's history of chronic constipation, abdominal distension, and the pathognomonic "inverted U-shaped colonic loop" (coffee bean sign) on radiograph indicate a sigmoid volvulus.
Establishing the underlying pathology is necessary to choose the specific treatment algorithm.
2
Assess the patient's severity and hemodynamic status.
The patient is hypotensive, tachycardic, febrile, and has an elevated lactate level with diffuse rebound tenderness and guarding (peritonitis).
The clinical stability and presence of peritonitis determine whether conservative/endoscopic management or emergent surgery is required.
3
Select the appropriate intervention based on the clinical severity.
Because peritonitis and hemodynamic instability indicate strangulated or gangrenous bowel, endoscopic decompression is contraindicated, and immediate open surgical exploration is necessary.
Resecting the necrotic bowel and achieving immediate source control is life-saving in this scenario.

Key Concept

Surgical management of complicated sigmoid volvulus
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Topics

Gastrointestinal and Abdominal Surgery

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