63 year old nursing home resident is brought to emergency room complaining of colicky abdominal pain, Nursing home staff reports that for several hours he has been complaining of nausea, abdominal distention, and a colicky type of left lower quadrant abdominal pain, He says the pain is continuous and severe, with a superimposed colicky camponent, He has had no bowel movements the past three days. He has never had abdominal surgery. His other medical problems include schizophrenia, for which he is on haloperidol as needed. He js allergic to sulfa, Family history is nothing significant. SH: He denies smoking and alcohol. How do you approach this patient?
Consider differential diagnosis: Bowel obstruction, -Ccarcinoma Pseudo-obstruction cileus}
Giant sigmoid diverticulum Constipation
Order physical examination: General appearance
Lungs
Heart
Abdomen
Rectal
Extremities
Results: Examination reveals a tympanitic/distended abdomen, Bowel sounds are diminished, There is no rigidity or rebound, Mild to moderate tenderness is present, Rectal examination shows only an empty rectal ampulla,
Order:
IY access
NP
IY NSd@100 cc/hr
CBC with diff, stat - Leukocytosis {in some cases Leukocytosis may be absent} SMA -¥ or BMP, stat ¢ to evaluate any electrolyte abnormality)
acray Of Abdomen, stat
Results:
CBC showed mild leukocytosis
SMA -F ois WAIL
Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with @ convex superior margin projecting into the night upper abdomen. Impression: Sigmoid volvulus,
Order review:
NG tube suction
GI consult (reason for consult: evaluation and decompression of sigmoid volvulus)
Sigmoidoscopy (decompression and untwisting of the sigmoid loop with placement of long soft tube} Rectal tube
Decision about changing patient’s location:
Admit ta ward
Continue I¥ fluid
Monitor patient for 2-3 days after decompression for persistent abdominal pain and bloodstained stools, signs that may herald ischemia and indicate the need for surgical intervention.
Consult General surgery- Emergency surgery is reserved for patients in whom tube decompression fails or for those in whom signs of ischemia are suggested.
After patient is stabilized, move patient home with office follaw-up in 5-7 days.
Educate patient and family: Console patient to seek medical care if nausea, vomiting, rectal bleeding, or abdominal pain reoccur, Console on low fat, high fiber diet,
Final Diagnosis: Sigmoid Valvulus
Explanation:
Sigmoaid volvulus is commonly seen in elderly patients who are institutionalized and debilitated fram neurological and psychiatric diseases, Typically, patients present with left lawer quadrant abdominal pain, nausea, abdominal distension, and constipation; Vomiting is less common and occurs late, The pain is usually continuous and severe, with 4 superimposed colicky component, Failure to diagnose and treat at the initial presentation causes colonic ischemia, gangrene, and perforation. Physical examination reveals a distended, tympanitic abdomen, and 4 palpable mass may be present, Bowel sounds are usually absent, Rectal examination shows empty rectal ampulla, Severe pain, tenderness, rigidity, and rebound tenderness suggest peritonitis resulting from ischemia/perforation,
In approximately 6096 of patients, diagnosis of sigmoid volvulus can be made by using plain abdominal radiagraphic findings, Supine radiograph of abdomen shows 4 markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. Also, dilated gas-filled lumen, can result in a coffee bean-shaped structure; i.e, the coffee bean sign, If diagnosis is questionable, a barium enema will confirm diagnosis but js contraindicated in suspected perforation,
The management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks. Sigmoidoscopy is the initial procedure of choice in patients with viable bowel, Sudden decompression is successful in 70-90% of cases, Many physicians subsequently place a rectal tube in situ, This non-operative approach is only 4a temporary measure, which allaws further medical assessment, preoperative care, and bowel preparation,
Location: Emergency roam ¥ital signs: B.P: 130/70 mm Hg; H.R: 80/min; R.R: 18/tmin; Termperature: 38,79C,