An 83-year-old man with mild cognitive impairment is transported from an assisted living facility with a 2-day history of abdominal pain and decreased oral intake. He has no vomiting, fever, or urinary symptoms. He underwent coronary artery bypass grafting 6 years ago. The patient also had a stent placed in his superficial femoral artery 3 years ago for claudication due to peripheral artery disease.
His temperature is 37.3° C (99.2° F), blood pressure is 127/77 mm Hg, and pulse is 102/min. He appears uncomfortable. Examination shows dry membranes. The abdomen is distended, diffusely tender, and tympanic to percussion. There is no rebound tenderness or rigidity.
Laboratory results are as follows:

Contrast abdominal imaging, shown below, reveals a large, air-filled sigmoid colon with absence of air in the rectum.

Which of the following is the best next step in managing this patient?

Question

An 83-year-old man with mild cognitive impairment is transported from an assisted living facility with a 2-day history of abdominal pain and decreased oral intake.  He has no vomiting, fever, or urinary symptoms.  He underwent coronary artery bypass grafting 6 years ago.  The patient also had a stent placed in his superficial femoral artery 3 years ago for claudication due to peripheral artery disease.
His temperature is 37.3° C (99.2° F), blood pressure is 127/77 mm Hg, and pulse is 102/min.  He appears uncomfortable.  Examination shows dry membranes.  The abdomen is distended, diffusely tender, and tympanic to percussion.  There is no rebound tenderness or rigidity.
Laboratory results are as follows:

Contrast abdominal imaging, shown below, reveals a large, air-filled sigmoid colon with absence of air in the rectum.

Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

This patient's presentation suggests sigmoid volvulus without perforation. Volvulus is due to an intestinal segmental torsion that may lead to obstruction or gangrene if untreated. It occurs most commonly in the sigmoid and cecum and less commonly in other portions of the gastrointestinal tract (eg, stomach, transverse colon, splenic flexure). Sigmoid volvulus is more common in elderly patients who are institutionalized or affected by neurologic or psychiatric conditions (eg, schizophrenia, Parkinson disease). Patients typically complain of abdominal pain, distention, constipation, and nausea. Plain abdominal x-ray is diagnostic in 60% of cases. X-ray shows a large air-filled sigmoid colon that extends from the pelvis to the right upper quadrant and absence of air in the rectum. In addition, distended proximal large bowel and air-fluid levels in the small intestine are commonly present. Air under the diaphragm or outside the bowel wall usually indicates perforation. Computed tomography scan usually shows dilated sigmoid colon (whirl pattern) around the mesocolon and vessels creating a bird beak appearance. Barium enema with water-soluble contrast can be helpful when the diagnosis is uncertain (Choice D). large air-filled sigmoid colon bird beak appearance Management is focused on preventing gangrene and correcting the underlying anatomic abnormality to reduce the risk of recurrence. Patients without gangrene or perforation (eg, fever, sepsis, peritonitis) need sigmoidoscopy to untwist the volvulus, restore blood supply, and assess colonic viability. However, sigmoidoscopy should be stopped if gangrene is present. Most endoscopists leave a rectal tube beyond the volvulus segment to further decompress the bowel and prevent recurrence. However, volvulus may reoccur in up to 60% of cases within a matter of hours to weeks. Surgery is reserved for patients with initial perforation/gangrene or recurrent volvulus despite conservative therapy (Choice E). (Choice B) Nasogastric suction is usually performed for complete or high-grade small-bowel obstruction to decompress the bowel. Antibiotics are not routinely administered for uncomplicated small-bowel obstruction. (Choice C) Though this patient has constipation (stool in the colon), oral lactulose and sodium phosphate enema are not useful in the treatment of sigmoid volvulus. Educational objective: Sigmoid volvulus is formed by twisting of a segment of the intestine, often leading to bowel obstruction and gangrene if untreated. Sigmoid volvulus is more common in elderly patients who are institutionalized or affected by neurologic or psychiatric conditions. Uncomplicated sigmoid volvulus is treated with sigmoidoscopy. Surgery is reserved for recurrent or complicated cases. __________ References: Management of sigmoid colon volvulus. (http://www.ncbi.nlm.nih.gov/pubmed/11100333) The twisted colon: a review of sigmoid volvulus. (http://www.ncbi.nlm.nih.gov/pubmed/22524761)

An 83-Year-Old Man with Mild Cognitive Impairment Is Transported from an Assisted