A 73-year-old female patient was admitted three times within three months to the gastrointestinal ward with recurrent painless abdominal distension. A week before her first admission she noticed progressive abdominal distension. Apart from nausea she experienced no other symptoms.
Her past medical history revealed breast carcinoma for which she had undergone a modified radical mastectomy in 1997 and resection of local recurrence combined with hormonal therapy in 2005. She was also known to have severe PD for more then twenty years. Medication consisted of levodopa/carbidopa and amantadine.
On physical examination at admission the patient was not very ill and had normal vital parameters. Her abdomen was grossly distended and high pitched bowel sounds were heard. The clinical diagnosis of an ileus was made. Laboratory tests were unremarkable without any sign of inflammation. An abdominal X-ray revealed a typical coffee bean-shaped sigmoid with gross dilatation up to 11 cm (Figure ).
Typical "bean-shaped" sigmoid with distension up to 11 cm representing sigmoid volvulus.
The patient was treated with enemas and laxatives. A colonoscopy was performed which did not reveal any mucosal irregularities. At 40 cm from the anus a strangulation of the sigmoid was seen with proximal dilatation of the colon which is pathognomonic for volvulus (Figure ). Surgical treatment was repeatedly considered but consistently refused by the patient. Decompression of the colon was finally established by a large (11 French) cannula inserted proximal from the evident torsion of the sigmoid (Figure ). Ten days after admission the patient was discharged in good clinical condition.
Endoscopic image of torsion of sigmoid: "Toffee-sign".
Colonic dilatation resolved after endoscopic detorsion with large bore rectal tube placement.
However, two months later she was readmitted with a recurrence of sigmoid volvulus. For the second time, conservative treatment with endoscopic derotation of the affected sigmoid and placement of a cannula for decompression was performed. To prevent further recurrence, a percutaneous endoscopic colostomy (PEC) was placed in the distal colon to achieve fixation to the abdominal wall (Figure ). No complications occurred. The patient was discharged a few days later. Two years later she was admitted with a third recurrence of sigmoid volvulus and was again successfully treated with endoscopic derotation. The patient still persists in her wish not to be operated on.
Percutaneous endoscopic colostomy has been placed.