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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 72-year-old man with a history of chronic constipation and Parkinson disease is brought to the emergency department with a 2-day history of progressive abdominal distension, obstipation, and crampy, lower abdominal pain. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respiratory rate is 16/min. Physical examination reveals a markedly distended, tympanitic abdomen with mild, diffuse tenderness but no guarding, rigidity, or rebound. Bowel sounds are high-pitched. Laboratory studies show mild leukocytosis (11,500/mm³) and a normal serum lactate level. Arrange the following management steps in the most appropriate chronological sequence for this patient.

  1. 1Initiate intravenous fluid resuscitation and bowel rest
  2. 2Obtain a computed tomography (CT) scan of the abdomen and pelvis
  3. 3Perform endoscopic detorsion via flexible sigmoidoscopy
  4. 4Schedule an elective definitive sigmoid colectomy

Answer

The correct sequence of management for uncomplicated sigmoid volvulus is initial stabilization with fluids, followed by diagnostic imaging (CT scan), therapeutic endoscopic detorsion, and finally elective sigmoid colectomy.
The patient presents with symptoms and signs suggestive of a large bowel obstruction, specifically sigmoid volvulus given his age, history of chronic constipation, and Parkinson disease. The correct sequence of management prioritizes stabilizing the patient (fluids and bowel rest), confirming the diagnosis and ruling out ischemia/perforation with a CT scan, acutely relieving the obstruction via endoscopic detorsion, and finally preventing recurrence with an elective sigmoid colectomy.

Step-by-Step Solution

1
Assess hemodynamic status and perform initial resuscitation.
The patient is hemodynamically stable without peritonitis. Intravenous fluids and bowel rest are initiated.
All patients with bowel obstruction require initial stabilization to correct volume depletion and electrolyte imbalances before proceeding to imaging or interventions.
2
Obtain cross-sectional imaging.
A CT scan of the abdomen and pelvis is performed.
Imaging is required to confirm the diagnosis of sigmoid volvulus, identify the point of transition, and most importantly, rule out ischemic bowel or free air that would mandate immediate surgery.
3
Relieve the acute obstruction.
Endoscopic detorsion via flexible sigmoidoscopy is performed.
In the absence of gangrene or perforation, endoscopic decompression is the first-line therapeutic step, allowing the acute obstruction to resolve and the bowel to be prepped.
4
Plan for definitive management.
An elective sigmoid colectomy is scheduled during the same admission.
Endoscopic detorsion has a high recurrence rate. A definitive resection during the same hospitalization prevents recurrence while allowing for a safer, single-stage operation on a decompressed, prepped colon.

Key Concept

Sequential management of uncomplicated sigmoid volvulus
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Topics

Gastrointestinal and Abdominal Surgery

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