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Zorluk: KolayGastrointestinal and Abdominal Surgery

A 75-year-old man is brought to the emergency department from an assisted living facility due to progressively worsening abdominal distension and failure to pass stool or flatus for the past 3 days. His medical history includes chronic constipation, hypertension, and schizophrenia. His vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, pulse 85/min, and respirations 16/min. On physical examination, the abdomen is massively distended and tympanitic to percussion, but there is no guarding or rebound tenderness. Digital rectal examination reveals an empty rectal vault. An upright abdominal X-ray demonstrates a markedly dilated loop of colon extending from the pelvis toward the right upper quadrant, resembling a "coffee bean," with no evidence of pneumoperitoneum. Which of the following is the most appropriate next step in management?

  1. Flexible sigmoidoscopyCevap
  2. B
    Urgent exploratory laparotomy
  3. C
    Nasogastric tube decompression and intravenous fluids
  4. D
    Intravenous neostigmine administration
  5. E
    Intravenous broad-spectrum antibiotics

Cevap

Flexible sigmoidoscopy is the most appropriate next step to therapeutically untwist the colon.
The correct answer is flexible sigmoidoscopy. This patient presents with the classic clinical and radiographic findings of a sigmoid volvulus, notably the characteristic "coffee bean" sign on an upright abdominal X-ray. In a hemodynamically stable patient without any evidence of peritonitis, bowel ischemia, or perforation, the most appropriate initial step is endoscopic detorsion using flexible sigmoidoscopy. This procedure is both diagnostic and therapeutic, allowing the clinician to untwist the affected bowel segment and place a rectal tube to maintain decompression and prevent immediate recurrence.

Adım Adım Çözüm

1
Identify the primary diagnosis based on the clinical presentation and radiographic imaging.
The patient has symptoms of a large bowel obstruction with a classic "coffee bean" sign on X-ray, which confirms the diagnosis of a sigmoid volvulus.
Establishing the correct etiology of the obstruction is essential before determining the appropriate intervention.
2
Assess the patient's clinical stability and look for signs of complications.
The patient has stable vital signs, a non-peritonitic abdomen (no guarding or rebound tenderness), and no free air on the X-ray, indicating an uncomplicated volvulus.
The presence of bowel ischemia or perforation completely changes the management pathway from endoscopic to surgical.
3
Select the most appropriate initial management for an uncomplicated sigmoid volvulus.
Flexible sigmoidoscopy.
Endoscopic detorsion is the first-line therapeutic step for a stable patient, allowing the bowel to be untwisted and decompressed.

Anahtar Kavram

Management of uncomplicated sigmoid volvulus
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Konular

Gastrointestinal and Abdominal Surgery

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