An 80-year-old bedridden woman presents with sudden massive abdominal distension and absolute constipation for 12 hours. Abdominal radiograph shows a grossly dilated loop of bowel arising from the pelvis with a coffee bean appearance, its apex directed towards the right upper quadrant, and a paucity of gas distally. Digital rectal examination reveals an empty rectum. After resuscitation, what is the most appropriate immediate management?

• A Emergency laparotomy with resection and primary anastomosis
• B Nasogastric decompression and conservative management with enemas
• C Barium enema reduction alone with discharge if successful
• D Flexible sigmoidoscopic detorsion followed by elective sigmoid colectomy during the same admission ✓

Explanation

The coffee bean loop with apex in the right upper quadrant and empty rectum on examination is classic sigmoid volvulus. In the absence of peritonitis, perforation, or gangrene, flexible sigmoidoscopic detorsion is the initial treatment of choice and decompresses the twist in most patients. Because recurrence rates are very high, elective sigmoid colectomy is advised during the same admission. Laparotomy is reserved for suspected gangrene or failed endoscopic detorsion, and barium enema reduction or conservative measures carry unacceptable risk of perforation.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.