A 75-year-old man presents with abdominal distension, absolute constipation, and a 'bent inner tube' or 'omega loop' sign on plain X-ray. The diagnosis and most appropriate initial management is:

• A Cecal volvulus; emergency right hemicolectomy
• B Small bowel obstruction; nasogastric tube decompression and IV fluids
• C Sigmoid volvulus; rigid sigmoidoscopy or flexible colonoscopy decompression as the first-line intervention ✓
• D Pseudo-obstruction (Ogilvie syndrome); neostigmine administration

Explanation

The 'bent inner tube' or 'coffee bean sign' pointing to the right upper quadrant on plain X-ray is pathognomonic of sigmoid volvulus. Initial management is endoscopic decompression via rigid sigmoidoscopy or flexible colonoscopy, which is successful in ~70–90% of cases and should be followed by elective sigmoid colectomy to prevent recurrence (recurrence rate ~50–90% without surgery). Emergency surgery (Hartmann's or primary anastomosis) is reserved for peritonism, signs of ischemia/perforation, or failed endoscopic decompression. Cecal volvulus shows the 'kidney bean' sign pointing to the left upper quadrant.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.