General Surgery · Year 3 · from General Surgery

Case 3: Large Bowel Obstruction from Sigmoid Volvulus

Patient Demographics

  • Age: 78 years
  • Sex: Male
  • Occupation: Retired, nursing home resident

Chief Complaint

"He hasn't had a bowel movement in 4 days and his belly is getting bigger."

History of Present Illness

The patient is brought from his nursing facility by EMS. According to nursing staff, he has had progressively worsening abdominal distension over the past 4 days with absence of bowel movements and minimal flatus. He has had several episodes of non-bilious vomiting today. He has become increasingly confused and lethargic. His baseline mental status includes mild dementia, but he is usually conversant and ambulatory with assistance. He has a history of chronic constipation requiring regular laxatives.

Past Medical History

  • Chronic constipation
  • Dementia (mild)
  • Parkinson's disease
  • Previous episode of sigmoid volvulus (decompressed endoscopically 2 years ago)
  • Hypertension
  • Type 2 diabetes

Medications

  • Carbidopa-levodopa
  • Metformin 500 mg twice daily
  • Lisinopril 20 mg daily
  • Polyethylene glycol daily
  • Senna as needed

Physical Examination

  • Vitals: BP 105/68 mmHg, HR 104 bpm, RR 22/min, Temp 37.8°C, SpO2 94% on room air
  • General: Elderly male, confused, uncomfortable
  • Abdomen:
  • Inspection: Massively distended, tympanitic
  • Auscultation: High-pitched, tinkling bowel sounds
  • Palpation: Diffuse tenderness, no peritoneal signs
  • No hernias palpable
  • Rectal exam: Empty rectal vault, no masses, guaiac negative

Laboratory Results

  • WBC: 11,800/μL
  • Hemoglobin: 12.4 g/dL
  • Creatinine: 1.8 mg/dL (baseline 1.2)
  • BUN: 48 mg/dL
  • Potassium: 3.2 mEq/L
  • Sodium: 131 mEq/L
  • Lactate: 2.1 mmol/L

Imaging

Abdominal X-ray:

  • Markedly dilated loop of large bowel in an inverted "U" shape
  • Classic "coffee bean" sign
  • Apex of the loop points toward the right upper quadrant
  • Small bowel dilation proximal to obstruction

CT Abdomen/Pelvis:

  • Sigmoid volvulus with "whirl sign" at the point of torsion
  • Massively dilated sigmoid colon (15 cm diameter)
  • No evidence of bowel wall ischemia or perforation
  • Transition point at the rectosigmoid junction

Diagnosis

Sigmoid volvulus without evidence of ischemia

Initial Management

  1. NPO status
  2. IV fluid resuscitation
  3. Nasogastric tube decompression
  4. Electrolyte replacement (potassium)
  5. Foley catheter
  6. Gastroenterology consultation for attempted endoscopic decompression

Endoscopic Decompression

Flexible sigmoidoscopy performed at bedside. Twisted sigmoid colon encountered at 25 cm. Gentle manipulation with scope achieved detorsion. Large volume of gas and liquid stool expelled. A rectal tube placed for continued decompression.

Post-Decompression Course

  • Abdominal distension improved significantly
  • Repeat abdominal X-ray showed resolution of volvulus
  • Bowel function returned POD 2
  • Diet advanced slowly
  • Surgical consultation for definitive management

Surgical Discussion

Given this is his second episode of sigmoid volvulus, elective sigmoid colectomy recommended after medical optimization to prevent recurrence (recurrence rate 40-60% without surgery). Patient and family counseled on risks and benefits. Decision made to proceed with surgery during this admission after nutritional optimization.

Definitive Surgery

Laparoscopic sigmoid colectomy with primary anastomosis performed on hospital day 7 after bowel preparation and nutritional support. Uneventful procedure with estimated blood loss of 75 mL.

Teaching Points

  1. Sigmoid volvulus is most common in elderly, institutionalized, and psychiatric patients
  2. "Coffee bean" sign on X-ray is pathognomonic
  3. Endoscopic decompression is first-line treatment if no signs of ischemia/perforation
  4. Definitive surgery (sigmoid resection) recommended after successful decompression to prevent recurrence
  5. Emergency surgery required if endoscopic decompression fails or signs of ischemia present

Clinical Image

Image Description: Abdominal radiograph demonstrating the classic "coffee bean" sign of sigmoid volvulus. The massively dilated sigmoid colon forms an inverted U-shape with the apex pointing toward the right upper quadrant. Air-fluid levels and proximal small bowel dilation are also visible.

Attribution: Image from Wikimedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/Category:Volvulus

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