Question

Difficulty: MediumSurgical and Procedural Interventions

An 84-year-old man who resides in a nursing care facility is transferred to the hospital due to progressively worsening abdominal swelling and failure to pass any gas or stool over the past three days. His medical history includes Parkinson disease, type 2 diabetes mellitus, and chronic constipation requiring daily laxatives. The patient complains of crampy abdominal discomfort but denies nausea, vomiting, or chills. On arrival, his temperature is 37.1∘37.1^\circ C (98.8∘98.8^\circ F), blood pressure is 138/84138/84 mmHg, pulse is 8686/min, and respiratory rate is 1616/min. Physical examination demonstrates a markedly distended, tympanic abdomen. The abdomen is diffusely and mildly tender to palpation, but there is no rigidity, guarding, or rebound tenderness. Digital rectal examination reveals an empty rectal vault. Laboratory studies show a leukocyte count of 7,600/μL7,600/\mu L and a serum lactate level of 1.01.0 mmol/L. An upright abdominal radiograph displays a massive, dilated loop of large bowel arising from the pelvis and projecting toward the right upper quadrant, characterized by an absence of haustral markings and a central double-wall thickness. Which of the following is the most appropriate next step in management?

  1. Flexible sigmoidoscopyAnswer
  2. B
    Urgent exploratory laparotomy
  3. C
    Computed tomography of the abdomen and pelvis with intravenous contrast
  4. D
    Intravenous neostigmine
  5. E
    Placement of a nasogastric tube and serial abdominal examinations

Answer

Flexible sigmoidoscopy
The correct answer is flexible sigmoidoscopy. This patient's presentation (elderly, nursing home resident, chronic constipation, psychiatric/neurologic comorbidities) combined with the classic 'coffee-bean' sign on an abdominal radiograph is diagnostic of a sigmoid volvulus. Because his vital signs are stable, his abdomen lacks peritoneal signs (no rigidity or rebound), and his laboratory markers for ischemia (leukocytes and lactate) are normal, he has an uncomplicated volvulus. The standard first-line management for uncomplicated sigmoid volvulus is endoscopic detorsion and decompression using a flexible sigmoidoscope (or rigid proctoscope). This allows the bowel to be untwisted non-operatively, stabilizing the patient and allowing for a safer, elective surgical resection (sigmoid colectomy) during the same hospital stay to prevent recurrence.

Step-by-Step Solution

1
Analyze the patient's demographic risk factors and clinical presentation.
The patient is an elderly male with a history of chronic constipation and Parkinson disease presenting with obstipation and marked abdominal distension.
These are classic risk factors for developing a sigmoid volvulus, which occurs when a redundant segment of the sigmoid colon twists on its mesentery.
2
Interpret the physical examination and laboratory findings to assess for complications.
The patient has normal vital signs, a soft abdomen without peritoneal signs, a normal leukocyte count, and normal serum lactate.
The absence of peritonitis or metabolic derangement indicates that the volvulus is uncomplicated, meaning there is no current evidence of bowel ischemia, gangrene, or perforation.
3
Evaluate the imaging findings provided in the vignette.
The upright abdominal radiograph reveals a large, dilated loop of colon arising from the pelvis with a central double-wall thickness.
This is the classic 'coffee-bean' sign, which is highly sensitive and specific for a sigmoid volvulus.
4
Determine the appropriate procedural intervention based on the uncomplicated status.
Endoscopic detorsion via flexible sigmoidoscopy is indicated.
In uncomplicated sigmoid volvulus, flexible sigmoidoscopy is both diagnostic and therapeutic, allowing for decompression and untwisting of the bowel while avoiding the immediate risks of surgery.

Key Concept

The primary management for an uncomplicated sigmoid volvulus (absence of peritonitis, perforation, or ischemia) is endoscopic detorsion using flexible sigmoidoscopy.
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