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Difficulty: MediumSurgical and Procedural Interventions

A 76-year-old man is brought to the emergency department from a nursing facility due to progressive abdominal distension, severe cramping abdominal pain, and failure to pass stool or flatus for the past 3 days. His medical history is notable for Parkinson disease, chronic constipation, and hypertension. His daily medications include carbidopa-levodopa, lisinopril, and an osmotic laxative.

His temperature is 37.1°C (98.8°F), blood pressure is 138/82 mm Hg, heart rate is 88/min, and respiratory rate is 16/min.

Physical examination reveals a markedly distended abdomen that is tympanitic to percussion. The abdomen is mildly tender diffusely but lacks rebound tenderness, rigidity, or guarding. Bowel sounds are absent.

An upright plain abdominal radiograph demonstrates a massively dilated loop of colon extending from the left lower quadrant toward the right upper quadrant, adopting a "coffee bean" appearance. There is no evidence of pneumoperitoneum.

Which of the following is the most appropriate next step in management?

  1. Flexible sigmoidoscopyAnswer
  2. B
    Exploratory laparotomy
  3. C
    Intravenous neostigmine
  4. D
    Computed tomography of the abdomen and pelvis with intravenous contrast
  5. E
    Discharge to the nursing facility with an aggressive bowel regimen

Answer

Flexible sigmoidoscopy
The correct answer is flexible sigmoidoscopy. The patient's presentation of progressive abdominal distension, obstipation, and a plain abdominal radiograph demonstrating a massively dilated colon loop pointing toward the right upper quadrant (the classic "coffee bean" sign) is highly specific for a sigmoid volvulus. Patients with a history of chronic constipation, neurologic conditions (e.g., Parkinson disease), or psychiatric disorders are at high risk. Because the patient's vital signs are stable and the physical examination shows no signs of peritonitis (such as rigidity or rebound tenderness) or bowel ischemia, the standard first-line management is non-operative. Flexible sigmoidoscopy allows for direct visualization, endoscopic detorsion of the twisted bowel segment, and placement of a decompression tube. Once the patient is decompressed and optimized, an elective sigmoid colectomy is typically performed during the same hospitalization due to the high risk of recurrence.

Step-by-Step Solution

1
Analyze the clinical presentation and radiograph
The patient has a large bowel obstruction with a classic "coffee bean" sign on the X-ray.
Identifying the specific type of obstruction (sigmoid volvulus) dictates the specific procedural intervention.
2
Assess the patient for signs of complications
The patient is hemodynamically stable and lacks peritoneal signs (no rigidity or rebound tenderness).
The presence of peritonitis or hemodynamic instability would mandate emergent surgical intervention.
3
Determine the most appropriate initial procedural intervention
Endoscopic detorsion via flexible sigmoidoscopy.
It is the standard first-line therapy for uncomplicated sigmoid volvulus to relieve the obstruction non-invasively.

Key Concept

In a hemodynamically stable patient with a sigmoid volvulus and no clinical signs of peritonitis or bowel ischemia, the initial treatment of choice is endoscopic detorsion and decompression via flexible sigmoidoscopy.
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Topics

Surgical and Procedural Interventions

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