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Difficulty: HardSurgical and Procedural Interventions

A 67-year-old woman is brought to the emergency department from a skilled nursing facility due to a 2-day history of progressively worsening abdominal pain, distension, and obstipation. She has a medical history significant for Parkinson disease, chronic constipation, and severe osteoarthritis. Her current medications include carbidopa-levodopa, polyethylene glycol, and acetaminophen. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 105/65 mmHg, heart rate of 115/min, and respiratory rate of 20/min. Physical examination reveals a markedly distended and tympanitic abdomen with diffuse tenderness. There is no rebound tenderness or guarding. Laboratory studies show a leukocyte count of 11,500/mm³ and normal serum electrolyte levels. An abdominal plain radiograph demonstrates a massively dilated, comma-shaped loop of bowel projecting from the right lower quadrant toward the left upper quadrant. A subsequent computed tomography scan of the abdomen shows a markedly distended cecum with mesenteric twisting and a transition point in the right colon. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomy and right hemicolectomyAnswer
  2. B
    Colonoscopy with active decompression and detorsion
  3. C
    Intravenous administration of neostigmine
  4. D
    Urgent computed tomography angiography of the mesenteric vessels
  5. E
    Fluoroscopy-guided water-soluble contrast enema

Answer

The most appropriate next step in management is exploratory laparotomy and right hemicolectomy.
The correct answer proposes immediate surgical intervention. A cecal volvulus involves axial twisting of the cecum, terminal ileum, and ascending colon. Because the anatomical twist makes endoscopic access very difficult and highly prone to perforation, endoscopic detorsion is generally unsuccessful and not recommended. The standard of care is urgent surgical intervention. A right hemicolectomy or ileocecal resection with primary anastomosis is the preferred procedure in a hemodynamically stable patient with viable bowel, as it definitive treats the obstruction and prevents recurrence.

Step-by-Step Solution

1
Analyze the clinical presentation and imaging findings.
The patient presents with signs of large bowel obstruction. The radiograph shows a dilated bowel loop projecting from the right lower quadrant to the left upper quadrant, and CT confirms a transition point in the right colon with mesenteric twisting.
These findings are classic for a cecal volvulus, which occurs when the cecum twists on its mesentery.
2
Differentiate the pathology from other similar conditions.
The pathology is identified as cecal volvulus, not sigmoid volvulus (which classically projects from the left lower quadrant to the right upper quadrant) or Ogilvie syndrome (which lacks a mechanical transition point or twist).
Accurate anatomical differentiation dictates the completely different procedural management required.
3
Determine the optimal procedural intervention based on the diagnosis.
Surgical intervention (laparotomy with right hemicolectomy or ileocecal resection) is selected as the necessary treatment.
Unlike sigmoid volvulus, cecal volvulus cannot be safely or effectively decompressed endoscopically. Immediate surgical resection is required to prevent or treat bowel ischemia and prevent recurrence.

Key Concept

Cecal volvulus requires immediate surgical intervention (e.g., right hemicolectomy) as opposed to sigmoid volvulus, which is initially managed with endoscopic detorsion.
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Topics

Surgical and Procedural Interventions

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