A 78-year-old man is brought to the emergency department due to progressive abdominal distention and inability to pass stool for the past 3 days. He reports crampy lower abdominal pain and nausea. His medical history is significant for Parkinson disease, chronic constipation, and hypertension. He takes carvidopa-levodopa and lisinopril. Temperature is 37.0°C (98.6°F), blood pressure is 130/78 mm Hg, pulse is 96/min, and respiratory rate is 16/min. Physical examination demonstrates a markedly distended, tympanitic abdomen with mild diffuse tenderness. There is no rebound tenderness or guarding. Laboratory studies are unremarkable. Abdominal radiography demonstrates a massively dilated loop of colon extending from the pelvis into the upper abdomen with a “coffee-bean” appearance.
Which of the following is the most appropriate next step in management?
The correct answer is:
B) Flexible sigmoidoscopic decompression
This patient has sigmoid volvulus, a common cause of large bowel obstruction in older adults. Several clues point to the diagnosis. His advanced age, history of chronic constipation, and Parkinson disease are important risk factors because chronic colonic dysmotility promotes elongation and redundancy of the sigmoid colon. The progressive abdominal distention and inability to pass stool indicate mechanical obstruction. The most important diagnostic clue is the classic “coffee-bean” sign on abdominal radiography, which results from twisting of the sigmoid colon around its mesenteric axis.
The critical next step is determining whether bowel compromise is present. This patient has no fever, leukocytosis, peritonitis, or signs of perforation, making uncomplicated sigmoid volvulus most likely. In stable patients without evidence of ischemia or perforation, endoscopic decompression with flexible sigmoidoscopy is both diagnostic and therapeutic. Following successful decompression, elective surgical resection is generally recommended because recurrence rates exceed 50%.
Step 2 commonly tests the distinction between uncomplicated and complicated volvulus. Patients with bowel ischemia, perforation, peritonitis, or failed endoscopic decompression require urgent surgical intervention. Another commonly tested distinction is cecal volvulus, which is generally managed surgically rather than endoscopically.
Answer choice A: Emergent laparotomy with bowel resection, is incorrect.
This is a tempting answer because volvulus can become a surgical emergency. However, surgery is reserved for patients with evidence of bowel ischemia, perforation, peritonitis, or unsuccessful endoscopic decompression. This patient is hemodynamically stable and lacks signs of bowel compromise, making endoscopic decompression the preferred initial intervention.
Answer choice C: Intravenous corticosteroids, is incorrect.
Corticosteroids are used in inflammatory conditions such as ulcerative colitis and Crohn disease. This patient has a mechanical large bowel obstruction rather than inflammatory disease.
Answer choice D: Oral polyethylene glycol, is incorrect.
The history of constipation may make a laxative seem reasonable. However, mechanical obstruction is present, and administration of laxatives can worsen distention and increase the risk of perforation.
Answer choice E: Upper endoscopy, is incorrect.
Upper endoscopy evaluates the esophagus, stomach, and proximal duodenum. It would neither diagnose nor treat a colonic obstruction caused by sigmoid volvulus.
Key Learning Point
Stable patients with sigmoid volvulus are treated initially with endoscopic decompression, whereas patients with bowel ischemia, perforation, or peritonitis require urgent surgery.
