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Difficulty: MediumGastrointestinal and Abdominal Surgery

An 82-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal swelling and a lack of bowel movements for the past three days. He has a history of Parkinson disease, hypertension, and chronic constipation. His medications include carbidopa-levodopa, amlodipine, and a daily multivitamin. On arrival, his temperature is 37.1°C (98.8°F), blood pressure is 138/82 mm Hg, pulse is 86/min, and respiratory rate is 16/min. Physical examination reveals a markedly distended, tympanitic abdomen. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Digital rectal examination demonstrates an empty rectal vault. Laboratory studies reveal a leukocyte count of 8,200/mm³ and normal serum electrolytes. A plain abdominal radiograph demonstrates a massively dilated large bowel loop resembling an inverted U-shape extending from the pelvis toward the right upper quadrant, with a loss of haustral markings. Which of the following is the most appropriate next step in management?

  1. Endoscopic detorsion via flexible sigmoidoscopyAnswer
  2. B
    Emergent exploratory laparotomy with bowel resection
  3. C
    Intravenous administration of neostigmine
  4. D
    Nasogastric tube insertion and intravenous fluid resuscitation
  5. E
    Oral administration of a polyethylene glycol solution

Answer

Endoscopic detorsion via flexible sigmoidoscopy
The correct answer is endoscopic detorsion via flexible sigmoidoscopy. This patient's presentation (elderly, chronic constipation, Parkinson disease) and classic radiographic findings (massively dilated large bowel resembling an inverted U-shape) are highly diagnostic of a sigmoid volvulus. Because he is hemodynamically stable, lacks fever, and has a non-rigid abdomen without rebound tenderness, the volvulus is considered uncomplicated (no evidence of ischemia or perforation). In such cases, the standard of care is therapeutic endoscopy, which allows the twisted segment to be directly visualized, decompressed, and detorsed. A rectal tube is often left in place to prevent immediate recurrence.

Step-by-Step Solution

1
Analyze the patient's demographics, history, and presentation.
An elderly male with neurologic comorbidity (Parkinson disease) and chronic constipation presenting with severe abdominal distension and obstipation.
These are the classic risk factors and presenting symptoms for a sigmoid volvulus.
2
Interpret the radiographic findings and physical examination.
The X-ray shows a massively dilated large bowel loop in an inverted U-shape (the 'coffee bean' or 'bent inner tube' sign). The physical exam shows a distended abdomen without guarding or rebound tenderness.
The X-ray confirms a sigmoid volvulus. The lack of peritonitis and normal vital signs confirm that the volvulus is 'uncomplicated' (no bowel ischemia or perforation).
3
Determine the appropriate treatment algorithm for uncomplicated sigmoid volvulus.
The initial treatment of choice is endoscopic decompression and detorsion.
Flexible sigmoidoscopy safely untwists the bowel and relieves the obstruction. Surgery is reserved for patients with peritonitis, bowel ischemia, or those who fail endoscopic detorsion.

Key Concept

The initial management of an uncomplicated sigmoid volvulus is endoscopic detorsion via flexible sigmoidoscopy.
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Topics

Gastrointestinal and Abdominal Surgery

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