Today we discussed a 69 year old man who presented with abdominal pain and obstipation and was ultimately found to have a sigmoid volvulus.
- Lower lobe pneumonia (get a CXR)
- ACS (EKG)
- Ovarian/testicular torsion (careful testicular exam)
- Pelvic inflammatory disease (careful history and physical)
- Large bowel obstruction more likely to require surgery than small bowel disease
- Mesenteric ischemia
- AAA rupture
If you’re concerned about perforation, start by getting an obstructive series, which consists of supine and upright KUBs as well as a left lateral decubitus film.
KUBs can detect as little as 1ml of air in the abdomen, but are still only 50-70% sensitive for intra-abdominal free air, so a CT is really the imaging test of choice.
This patient’s imaging revealed at first that he had a large bowel obstruction!
- Large bowel obstruction
- Causes: cancer, volvulus (sigmoid > cecal), less commonly: adhesions, diverticular strictures, IBD, intussusception, ischemic colitis strictures
- p/w progressive abdominal pain, distention and obstipation
- rapid onset distention/obstipation, slower onset nausea/vomiting (less common unless proximal obstruction)
- Small bowel obstruction
- Causes: post-op adhesions, malignancy, hernias, IBD, strictures, volvulus (less common)
- p/w acute abdominal pain and nausea/vomiting
- rapid onset nausea/vomiting, slower onset constipation/distention
Further testing revealed sigmoid volvulus, which is more common in African Americans and across the volvulus belt (Africa, Middle East, India, parts of Russia)
Key differences in SBO and LBO management
- SBO: can often be managed conservatively (NG tube, bowel rest)
- LBO: may require GI input for endoscopic detorsion (if volvulus), and ultimately surgery given high rate of recurrence of sigmoid volvulus (70%), or if cause is malignant
Gingold et al. Management of Colonic Volvulus. 2012 Dec. Clin Colon Rectal Surg.