Question Of The Day #37

This elderly male patient presents to the emergency department with generalized abdominal pain and distension. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The abdominal X-ray demonstrates a “coffee bean sign” and dilated loops of the large bowel (note haustra of the large bowel). The image supports the diagnosis of sigmoid volvulus, a type of large bowel obstruction that necessitates prompt surgical consultation in the Emergency department. Risk factors for sigmoid volvulus are elderly age, constipation, poor mobility, and residence in a long-term care facility. If left untreated, volvulus can result in intestinal ischemia, necrosis, perforation, and peritonitis. Sigmoid volvulus is most often treated with manual intestinal detorsion through flexible sigmoidoscopy or rectal tube. Cecal volvulus is more common in younger patients, and requires surgical bowel resection or cecopexy (fixing the cecum to the abdominal wall).

The abdominal X-ray provided is sufficient to make the diagnosis of volvulus. A CT scan of the abdomen and pelvis (Choice A) is not necessary for this patient. Surgical consultation is the next best step. IV antibiotics (Choice D) are indicated in volvulus if there are signs of intestinal perforation, necrosis, or peritonitis. The question stem indicates that although the abdomen is tender and distended, the abdomen is soft. This makes peritonitis and the need for antibiotics less likely. Surgical consultation for colectomy (Choice B) would be correct if the patient had cecal volvulus or if there were signs of bowel necrosis. Surgical consultation for bowel detorsion (Choice C) is the best next step for this patient with sigmoid volvulus. Correct Answer: C