Question Of The Day #37

question of the day
25.1 - obstruction volvulus coffee bean 1

Which of the following is the most appropriate next step in management for this patient?

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


Cite this article as: Joseph Ciano, USA, "Question Of The Day #37," in International Emergency Medicine Education Project, April 30, 2021,, date accessed: March 26, 2023

Question Of The Day #36

question of the day
Which of the following is the most likely diagnosis of this patient’s condition?

A hernia is an abnormal defect in the abdominal wall through which intra-abdominal contents (i.e., bowel) can protrude. About 10% of the population experiences hernias at one time during their lifetime. Hernias can cause symptoms that range from mild discomfort to severe pain with signs of bowel obstruction, perforation, necrosis, or peritonitis. The most common type of hernia is the inguinal hernia located along the inguinal crease. Other hernias include the femoral hernia, obturator hernia, Richter hernia, internal hernias, and ventral hernias (umbilical, incisional, Spigelian hernia types). Hernias are further classified as reducible, incarcerated (firm, painful, nonreducible), or strangulated (firm, severely painful, nonreducible, overlying skin redness or crepitus, signs of bowel necrosis or obstruction).

This patient has a right inguinal hernia on exam with overlying skin redness, severe tenderness, and signs of intestinal obstruction (vomiting, constipation, abdominal distension). This should raise concern over a strangulated hernia, which is a surgical emergency. Treatment includes IV hydration, IV antibiotics, and prompt surgical consultation for operative management. The patient’s inguinal hernia is not incarcerated (Choice A), the hernia is strangulated. A Spigelian hernia (Choice B) is located along the lateral ventral abdomen along with the rectus abdominal muscle. Spigelian hernias have a high rate of incarceration compared to other hernias. This patient’s hernia is located along the inguinal crease, not the ventral abdominal wall. Fournier’s gangrene is a severe necrotizing fasciitis of the perineum. Although early Fournier’s gangrene may lack subcutaneous emphysema and marked skin redness, the location and other historical details make a strangulated inguinal hernia a more likely diagnosis. Choice D is the correct answer.

Correct Answer: D


Cite this article as: Joseph Ciano, USA, "Question Of The Day #36," in International Emergency Medicine Education Project, April 23, 2021,, date accessed: March 26, 2023

Question Of The Day #35

question of the day
29.2 - small bowel obstruction 2
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the emergency department with generalized abdominal pain, nausea, vomiting, and constipation. The physical exam demonstrates tachycardia and a distended and diffusely tender abdomen. The patient has three prior abdominal surgeries. The upright abdominal X-ray shows multiple dilated loops of small bowel with air-fluid levels. The information provided by the history, physical exam, and diagnostic imaging collectively supports a diagnosis of small bowel obstruction.

Small bowel obstruction (SBO) is a mechanical blockage to forward flow through the intestines. The majority of SBOs are caused by post-operative scar tissue formation (adhesions), but other causes include hernias, intra-abdominal malignancies, foreign bodies, and Crohn’s disease. Symptoms include intermittent colicky abdominal pain, abdominal distension, nausea and vomiting, and constipation. Some patients may be able to pass stool and flatus early in the timeline of an SBO or if the obstruction is partial, rather than complete. Typical exam findings in SBO are a diffusely tender abdomen and high-pitched bowel sounds. Findings of abdominal rigidity, guarding, or fever should raise concern about possible intestinal perforation, peritonitis, or intestinal necrosis. Diagnosis is made clinically in combination with diagnostic imaging, such as abdominal X-rays, CT scanning, or ultrasound. CT scans have better sensitivity and specificity in diagnosing an SBO than Xray. Abdominal ultrasound is more sensitive and specific in diagnosing SBO than CT scan, but this test requires a skilled practitioner to get high-quality results. Treatment of SBO involves IV hydration, surgical consultation for possible operative intervention, pain medications, antiemetics, and electrolyte repletion. Nasogastric tube placement for gastric decompression is helpful in patients who have marked abdominal distension, intractable vomiting, or have risks for aspiration (i.e. altered mental status).

The most common cause of SBO is adhesions (Choice B), not malignancy (Choice A). Diabetic ketoacidosis (Choice C) can present with abdominal pain, nausea, and vomiting. However, DKA becomes more likely when the glucose is elevated over 250mg/dL. The presence of air-fluid levels and dilated small bowel on X-ray imaging also supports SBO over DKA. Delayed gastric emptying (Choice D) is the cause of gastroparesis, a diagnosis that can also present as nausea and vomiting. The other signs, symptoms, and imaging results make SBO a more likely diagnosis than gastroparesis.


Cite this article as: Joseph Ciano, USA, "Question Of The Day #35," in International Emergency Medicine Education Project, April 16, 2021,, date accessed: March 26, 2023