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An 83-year-old woman with Alzheimer dementia presented to the emergency department with abdominal distention. Her husband provided the history. After having constipation for 1 week, she developed a progressively distended abdomen in the course of 2 days, with anorexia but no vomiting, melena, or hematochezia. She had no history of fever, rigors, dyspnea, or weight loss. Her medical history was remarkable for hypertension, coronary artery disease, and impaired fasting blood glucose levels. Despite the recent symptoms, she had no history of gastroenterologic symptoms, cancer, abdominal surgeries, or colon screening studies. She lived with her husband in the community and was dependent on him for her activities of daily living except for ambulation with a walker and feeding herself. She was a nonsmoker and nondrinker. Her medications were 60 mg/d of isosorbide mononitrate, 325 mg/d of aspirin, 2.5 mg/d of amlodipine, 20 mg/d of atorvastatin, and a combination of 37.5 mg/d of triamterene and 25 mg/d of hydrochlorothiazide.
On examination, the patient appeared to be in mild distress with abdominal distention. Her vital signs were as follows: temperature, 36.6°C; blood pressure, 154/89 mm Hg; regular pulse, 84 beats/min; respiration rate, 20 breaths/min; and oxygen saturation, 94% while breathing room air. Abdominal examination revealed marked distention with diminished bowel sounds and moderate discomfort with deep palpation of the left lower quadrant, but no peritoneal irritation signs, Murphy sign, McBurney point tenderness, abdominal bruit, ascites, hepatosplenomegaly, or palpable mass. Rectal examination revealed no stool in the vault and no obvious mass.
The patient had normal levels of hemoglobin, white blood cells, platelets, chloride, bicarbonate, creatinine, blood urea nitrogen, troponin, and lipase, as well as a prothrombin time within the normal range. She had a serum sodium of 126 mEq/L (reference ranges provided parenthetically) (135-145 mEq/L), a potassium level of 2.5 mmol/L (3.6-4.8 mmol/L), and a blood glucose level of 198 mg/dL (70-100 mg/dL). Urinalysis was positive for trace occult blood and 1+ protein. Abdominal plain radiography showed prominent gaseous dilatation of the transverse colon and redundant sigmoid colon without distinct signs of obstruction or free air.
Sigmoid volvulus is a common and potentially life-threatening condition occurring in older, frail adults. A volvulus of the colon occurs in the sigmoid region about 40% of the time.10 Patients usually have symptoms of continuous abdominal pain, distention, nausea, and constipation. Often vomiting does not occur or occurs infrequently. These symptoms often seem nonspecific and are even less specific in patients unable to verbalize symptoms. On plain radiography, “bent inner-tube appearance” (severely distended sigmoid loop) is the classic finding. Some authors describe the dilated twisted sigmoid loop as an “inverted U” or “omega sign.”4 Clinicians often observe a lack of gas in the rectum distal to the obstruction and dilated descending colon.4 Typical computed tomographic findings include a “bird-beak appearance” and a “whirl pattern” of the dilated twisted sigmoid.4
The appropriate management should relieve the volvulus, reestablish the blood perfusion to the affected colon, and prevent possible future recurrence. The presence of gangrenous bowel is a major predictor of mortality. Endoscopic reduction of sigmoid volvulus alone is associated with a significant risk of recurrence; hence, sigmoid resection with coloproctostomy or end colostomy should follow endoscopic decompression. Laparoscopic sigmoidectomy minimizes surgical complications and shortens recovery time.11 It provides a promising alternative for elderly patients with chronic illness.
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Correct answers: 1. e, 2. b, 3. d, 4. e, 5. a