A 78-year-old woman is brought from the nursing home to the emergency department due to worsening abdominal distension. Over the past 3 days, the patient has had decreased appetite and progressive abdominal distension that is now accompanied by diffuse abdominal discomfort. Her last bowel movement was 4 days ago. Medical history is significant for dementia, hypertension, osteoarthritis, osteoporosis, and chronic constipation. Surgical history includes open appendectomy and open cholecystectomy. Temperature is 37 C (98.6 F), blood pressure is 138/80 mm Hg, and pulse is 92/min. Physical examination shows a distended and tympanitic abdomen with diffuse tenderness to palpation but no rigidity or rebound tenderness. Blood counts and serum electrolytes are within normal limits. Abdominal x-ray is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 78-year-old woman is brought from the nursing home to the emergency department due to worsening abdominal distension.  Over the past 3 days, the patient has had decreased appetite and progressive abdominal distension that is now accompanied by diffuse abdominal discomfort.  Her last bowel movement was 4 days ago.  Medical history is significant for dementia, hypertension, osteoarthritis, osteoporosis, and chronic constipation.  Surgical history includes open appendectomy and open cholecystectomy.  Temperature is 37 C (98.6 F), blood pressure is 138/80 mm Hg, and pulse is 92/min.  Physical examination shows a distended and tympanitic abdomen with diffuse tenderness to palpation but no rigidity or rebound tenderness.  Blood counts and serum electrolytes are within normal limits.  Abdominal x-ray is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d840_1db0_bc81_dbf97bb382a5_MD0003_00 This elderly patient with dementia and chronic constipation has slowly progressive (eg, over 3 days) abdominal distension/discomfort accompanied by likely obstipation (inability to pass stool or gas); this presentation is classic for sigmoid volvulus. Sigmoid volvulus occurs when the sigmoid colon twists on its mesentery, forming a closed-loop obstruction. With continued gas formation by intraluminal bacteria, the lumen of the obstructed bowel loop gradually expands. This is often visualized on abdominal x-ray as a dilated, inverted, U-shaped loop of the colon with a "coffee bean" appearance. inverted, U-shaped loop Management depends on whether perforation or peritonitis is present: Patients with perforation or peritonitis require emergency laparotomy and sigmoid colectomy (resection of the twisted/necrotic bowel). Patients without perforation or peritonitis, like this patient, should undergo flexible sigmoidoscopy, which can be used to examine colonic viability and endoscopically reduce the twisted segment. Successful most of the time (~75%-95%), flexible sigmoidoscopy allows elective surgery (eg, to prevent recurrences) to be performed after full bowel preparation. (Choice A) Emergency total abdominal colectomy may be lifesaving for those with toxic megacolon, but such patients are typically systemically ill (eg, fever, hypotension) and have x-ray findings of diffuse dilation of the colon within its normal anatomic arrangement (vs in a loop). In sigmoid volvulus, only the involved colon is removed. diffuse dilation of the colon (Choice B) Manual disimpaction and laxative therapy may be used for severe constipation with fecal impaction, but constipation without volvulus typically appears on x-ray as large amounts of stool in the colon. Peristalsis-inducing agents (eg, laxatives) are contraindicated for closed-loop obstructions (eg, volvulus) because they increase the risk of perforation. large amounts of stool in the colon (Choice C) Nasogastric decompression and bowel rest may be used to manage small-bowel obstruction (SBO). Although SBO can cause anorexia and abdominal distension, x-ray typically reveals multiple, dilated small-bowel loops with air-fluid levels and decompressed large bowel distal to the obstruction. dilated small-bowel loops with air-fluid levels (Choice E) Upper gastrointestinal series with small-bowel follow-through may be used to detect obstruction (eg, tumor, stricture) within the upper gastrointestinal tract (eg, stomach, small bowel). This patient's x-ray, which reveals a single, dilated colonic loop and proximal colonic dilation, is more consistent with lower gastrointestinal tract obstruction. Educational objective: Sigmoid volvulus often presents as slowly progressive abdominal discomfort/distension in an elderly patient and a "coffee bean"-shaped dilated loop of colon on abdominal x-ray. Patients without perforation or peritonitis can undergo flexible sigmoidoscopy to reduce the twisted segment and avoid emergency surgery. References: Volvulus. (http://www.ncbi.nlm.nih.gov/pubmed/30243456)

A 78-Year-Old Woman Is Brought from the Nursing Home to the Emergency