ABDOMINAL DISTENSION AND PAIN
A 70-year-old man has been sent to the emergency department from a nursing home, complaining of intermittent sharp abdominal pain. He has not opened his bowels for 5 days. He suffered a major stroke in the past and requires constant nursing care. He has a history of chronic constipation. Previous medical history includes chronic obstructive airways disease for which he is on regular inhalers. He is allergic to penicillin and is an ex-smoker.
His blood pressure is 110/74mmHg and the pulse rate is 112/min. His temperature is 37.8°C.
There is gross abdominal distension with tenderness, most marked on the left-hand side.
The abdomen is resonant to percussion and digital rectal examination reveals an empty
rectum. There is a soft systolic murmur and mild scattered inspiratory wheeze on auscultation of the chest.
• What does the abdominal X-ray show?
• What other radiological investigation could be employed if the diagnosis was in doubt?
• How should the patient be managed?
• What is the explanation for the pathology?
The X-ray shows a sigmoid volvulus. The sigmoid colon is grossly dilated and has an inverted U-tube shape. The involved bowel wall is usually oedematous and can form a dense central white line on the radiograph. On either side, the dilated loops of apposed bowel give the characteristic ‘coffee bean’ sign. X-ray appearances are diagnostic in 70 per cent of patients.
If there is doubt about the diagnosis, a water-soluble contrast may be helpful in showing a classical ‘bird’s beak’ appearance representing the tapered lumen of the colon.
The flatus tube is left in situ for approximately 48 h and is often only a temporary measure. Colonoscopy can be used to decompress the bowel and may resolve the volvulus.
Urgent laparotomy will be required if decompression is not possible or in cases of suspected gangrene/perforation (fever, leucocytosis, peritonism, free air under the diaphragm on erect chest radiography). The patient’s fitness for surgery, prognosis and quality of life should be considered before proceeding to laparotomy. It may be appropriate to use only
conservative treatments in some patients.
Sigmoid volvulus is predisposed to by a long, narrow mesocolon, chronic constipation or a high-roughage diet. The rotation of the gut can lead to obstruction and intestinal ischaemia. The sigmoid is the commonest part of the colon for this to occur, although the caecum and splenic flexure are other potential sites.
Treatment of sigmoid volvulus !
• Keep patient nil by mouth
• Intravenous access and fluids
• Fluid balance monitoring
• Routine bloods and crossmatch
• Erect chest X-ray/abdominal X-ray
• Decompression with rigid sigmoidoscopy and insertion of a flatus tube once the diagnosis is confirmed on abdominal X ray.