Soru

Zorluk: ZorSurgical and Procedural Interventions

A 7878-year-old woman is brought to the emergency department from a skilled nursing facility due to severe abdominal pain and altered mental status. Staff report that she has had progressive abdominal distention, nausea, and no bowel movements for the past 33 days. Her past medical history is significant for Parkinson disease, chronic constipation, and moderate Alzheimer dementia. Her temperature is 38.6∘C38.6^\circ\text{C} (101.5∘F101.5^\circ\text{F}), pulse is 122/min122/\text{min}, blood pressure is 85/55 mmHg85/55\text{ mmHg}, and respirations are 24/min24/\text{min}. Physical examination reveals a massively distended abdomen that is diffusely tender to palpation, with severe rigidity and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 18,500/mm318,500/\text{mm}^3 and a serum lactate level of 4.8 mmol/L4.8\text{ mmol/L}. An upright abdominal radiograph demonstrates a markedly dilated loop of colon extending from the pelvis to the right upper quadrant in an inverted U-shape, lacking haustra. Which of the following is the most appropriate next step in management?

  1. Emergent exploratory laparotomyCevap
  2. B
    Flexible sigmoidoscopy
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Admission to the intensive care unit for serial abdominal examinations
  5. E
    Transition to comfort-focused care and transfer back to the facility

Cevap

Emergent exploratory laparotomy
The correct intervention is emergent exploratory laparotomy. This patient's presentation of massive abdominal distention, obstipation, and an inverted U-shaped loop of colon on radiography is diagnostic of sigmoid volvulus. While the textbook initial step for an uncomplicated sigmoid volvulus is endoscopic detorsion via flexible sigmoidoscopy, this patient has signs of a complicated volvulus: peritonitis (rigidity, involuntary guarding), bowel ischemia (lactic acidosis), and septic shock (fever, tachycardia, hypotension). In this setting, endoscopic detorsion is strictly contraindicated due to the high risk of perforation and failure to remove necrotic bowel. Immediate surgical exploration (often involving resection of the necrotic sigmoid colon and creation of an end colostomy, known as a Hartmann's procedure) is life-saving and necessary.

Adım Adım Çözüm

1
Analyze the clinical presentation and vital signs.
The patient has septic shock (hypotension, tachycardia, fever) and an acute abdomen (rigidity, guarding) with elevated lactate.
Identifying the severity of the patient's condition dictates whether management can be conservative, diagnostic, or requires immediate surgical intervention.
2
Correlate the physical findings with the radiographic evidence.
An inverted U-shape ('coffee bean' sign) lacking haustra is classic for sigmoid volvulus. Combined with peritonitis, this indicates complicated sigmoid volvulus with likely bowel ischemia or impending perforation.
Connecting the specific anatomical obstruction to the systemic inflammatory response confirms the exact etiology of the acute abdomen.
3
Determine the optimal procedural intervention.
Select exploratory laparotomy, bypassing non-operative endoscopic detorsion.
Endoscopic detorsion is contraindicated when peritonitis or bowel ischemia is present; surgical resection of the necrotic colon segment is required.

Anahtar Kavram

Patients with sigmoid volvulus who exhibit signs of peritonitis, bowel ischemia, or perforation require immediate exploratory laparotomy, whereas those with uncomplicated presentations can safely undergo endoscopic detorsion.
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