A 70-year-old woman presents with abdominal pain, absolute constipation, and a massively distended abdomen. Plain X-ray shows a 'coffee bean' sign with the apex pointing to the right upper quadrant. CT confirms the diagnosis. The most appropriate initial management is:
- A Emergency laparotomy with sigmoid colectomy
- B Endoscopic detorsion via rigid sigmoidoscopy/colonoscopy as first-line treatment, with elective sigmoid colectomy after bowel preparation ✓
- C IV fluids and nasogastric tube, observe for 24 hours
- D Gastrografin enema for detorsion
Correct answer: B. Endoscopic detorsion via rigid sigmoidoscopy/colonoscopy as first-line treatment, with elective sigmoid colectomy after bowel preparation
Explanation
The 'coffee bean' sign with apex pointing to the right upper quadrant is pathognomonic of sigmoid volvulus. Endoscopic detorsion (rigid sigmoidoscopy or flexible colonoscopy with rectal tube placement) is the treatment of choice for non-gangrenous sigmoid volvulus, achieving decompression in >80% of cases. After successful detorsion and bowel preparation, elective sigmoid colectomy is recommended to prevent recurrence (risk >60%). Emergency laparotomy is required if there are signs of gangrene, peritonism, or failed endoscopic detorsion.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.