Review Question - QID 103067

This elderly patient presents with signs and symptoms of sigmoid volvulus (SV), and requires prompt derotation and decompression with a sigmoidoscopy or colonoscopy, followed by rectal tube placement and observation for signs of bowel ischemia.

SV is the third leading cause of colonic obstruction in adults. It manifests as a result of redundant sigmoid loops, which can rotate about their narrow mesentery leading to obstruction and ischemia. Initial management of SV is as described above, with definitive surgery following initial successful decompression. Detorsion and decompression is successful in well over 50% of patients, allowing for time to electively operate on the patient. Once detorsed, sigmoid resection with primary anastomosis is the procedure of choice, though more extensive procedures may be required, depending on the extent of colonic damage. Detorsion should be attempted in patients who present with no signs of rupture (i.e. peritonitis), and who are hemodynamically stable.

Figure/Illusration A shows an abdominal x-ray demonstrating dilated loops of large bowel, with characteristic coffee bean sign (red line), concerning for sigmoid volvulus.

Incorrect Answers:
Answer 2: A barium enema is not indicated in this patient, as a diagnosis is readily made via abdominal x-ray.
Answer 3: Immediate laparotomy with hartmann's procedure is not the management of choice for sigmoid volvulus, especially given that this patient shows no signs of hemodynamic instability.
Answer 4: Though sigmoidectomy and primary anastomosis is the procedure of choice, detorsion and decompression via sigmoidoscopy should be attempted first.
Answer 5: NPO, NG tube decompression, and neostigmine are possible treatments for colonic pseudo-obstruction (Ogilvie's Syndrome).