Examkin

Question

Difficulty: MediumSurgical and Procedural Interventions

An 82-year-old man who resides in a skilled nursing facility is evaluated in the emergency department for a two-day history of progressively worsening abdominal pain, an inability to pass flatus, and recurrent bilious vomiting. He has a history of Parkinson disease, chronic constipation, and hypertension. His daily medications include carbidopa-levodopa, lisinopril, and polyethylene glycol. His temperature is 38.6°C (101.5°F), blood pressure is 88/56 mm Hg, pulse is 122/min, and respirations are 24/min. On physical examination, the patient appears lethargic and is in significant distress. The abdomen is grossly distended and tympanitic. There is marked rigidity, involuntary guarding, and rebound tenderness across all quadrants. Bowel sounds are absent. A digital rectal examination reveals an empty rectal vault. Laboratory studies show a leukocyte count of 19,200/mm³ and a serum lactate level of 4.8 mmol/L. An anteroposterior abdominal radiograph reveals a massively dilated large bowel loop resembling a "coffee bean" extending from the pelvis toward the right upper quadrant. Which of the following is the most appropriate next step in management?

  1. A
    Flexible sigmoidoscopy with detorsion
  2. Emergent exploratory laparotomyAnswer
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Water-soluble contrast enema
  5. E
    Nasogastric tube decompression and hospital admission for observation

Answer

Emergent exploratory laparotomy
The most appropriate next step in management is an emergent exploratory laparotomy. This patient's presentation of massive abdominal distention, obstipation, and an abdominal radiograph showing a "coffee bean" sign is highly characteristic of a sigmoid volvulus. While an uncomplicated sigmoid volvulus is typically managed with flexible sigmoidoscopy to decompress and detorse the bowel, this patient is exhibiting clear signs of a complicated volvulus, specifically bowel ischemia or gangrene. These signs include fever, hemodynamic instability (hypotension, tachycardia), severe lactic acidosis, and frank peritonitis (rigidity, guarding, and rebound tenderness). When peritonitis or bowel compromise is present, endoscopic interventions are strictly contraindicated due to the high risk of exacerbating a perforation. The patient requires immediate fluid resuscitation and an emergent laparotomy to resect the necrotic segment of the colon (often via a Hartmann procedure).

Step-by-Step Solution

1
Identify the primary diagnosis based on clinical and radiographic findings.
Sigmoid volvulus.
The patient is an elderly individual with chronic constipation presenting with severe abdominal distention and an abdominal radiograph showing the classic "coffee bean" sign.
2
Assess for complications that alter the management pathway.
The patient has peritonitis and likely bowel ischemia.
Clinical examination reveals a rigid abdomen with rebound tenderness, accompanied by fever, hemodynamic instability (tachycardia, hypotension), leukocytosis, and lactic acidosis.
3
Determine the appropriate procedural intervention.
Emergent exploratory laparotomy.
In the setting of a complicated volvulus (gangrene, peritonitis, or perforation), endoscopic detorsion is contraindicated; immediate surgical source control with likely bowel resection is required.

Key Concept

Surgical management of complicated sigmoid volvulus
Rate this question

Topics

Surgical and Procedural Interventions

More questions from this topic