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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 7676-year-old man from a nursing home is brought to the emergency department due to a 33-day history of progressive abdominal distension, colicky abdominal pain, and obstipation. His temperature is 37.4∘C37.4^\circ\text{C} (99.3∘F99.3^\circ\text{F}), blood pressure is 118/76118/76 mm Hg, and pulse is 9292/min. Physical examination reveals a markedly distended, tympanitic abdomen without rebound tenderness or guarding. Arrange the following management steps in the most appropriate sequential order for this patient.

  1. 1Establish peripheral intravenous access and initiate crystalloid fluid resuscitation.
  2. 2Obtain a plain abdominal radiograph to confirm the diagnosis.
  3. 3Perform flexible sigmoidoscopy to attempt endoscopic detorsion.
  4. 4Schedule an elective sigmoid colectomy prior to hospital discharge.

Answer

The correct sequence of management is: fluid resuscitation, followed by plain abdominal radiography, then flexible sigmoidoscopy for detorsion, and finally scheduling an elective sigmoid colectomy.
The correct management sequence for an uncomplicated sigmoid volvulus strictly prioritizes physiological stabilization, followed by diagnostic confirmation, acute non-operative therapeutic intervention, and finally definitive surgical prevention. Fluid resuscitation is always the fundamental first step in a patient with a bowel obstruction to correct intravascular volume deficits. Once hemodynamically supported, an abdominal radiograph confirms the diagnosis (showing a distended, U-shaped colon). Because there are no signs of peritonitis or perforation, flexible sigmoidoscopy is safely indicated to untwist and decompress the colon. Finally, due to extremely high recurrence rates after detorsion alone, an elective sigmoid colectomy should be performed during the same hospital admission.

Step-by-Step Solution

1
Assess hemodynamic status and initiate supportive care.
Peripheral intravenous access is established and crystalloid fluids are administered.
Patients with intestinal obstruction are at high risk for significant volume depletion. This must be addressed before any diagnostic or therapeutic procedure to prevent hemodynamic collapse.
2
Confirm the suspected diagnosis of sigmoid volvulus with imaging.
A plain abdominal radiograph is obtained.
While the clinical presentation strongly suggests a large bowel obstruction, imaging is required to confirm the specific diagnosis and rule out complications like gross pneumoperitoneum.
3
Perform a minimally invasive intervention to relieve the obstruction.
Flexible sigmoidoscopy is performed for endoscopic detorsion and decompression.
Because the patient lacks signs of peritonitis or bowel ischemia, endoscopic decompression avoids the high morbidity of emergent surgery and acutely resolves the volvulus.
4
Plan definitive surgical management to prevent future recurrence.
An elective sigmoid colectomy is scheduled.
Sigmoid volvulus has a recurrence rate of up to 40-60% following successful endoscopic detorsion alone. Definitive surgical treatment should be performed during the same hospitalization once the patient's bowel is decompressed.

Key Concept

Management sequence for uncomplicated sigmoid volvulus
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Topics

Gastrointestinal and Abdominal Surgery

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