69-Year-Old Man With Abdominal Pain and Obstipation

Abstract

A 69-year-old man presented with a 4-day history of progressive, sharp, nonradiating, nonpositional diffuse abdominal pain and obstipation (inability to pass stool or flatus). Associated symptoms included a 1-day history of intermittent nausea without emesis. He reported no fevers, chills, night sweats, melena, hematochezia, weight loss, or altered bowel habits. Of note, he had presented 5 years earlier with similar symptoms, which resolved with conservative management. Otherwise, he had no history of altered bowel habits. His medical history was notable for hypothyroidism treated with replacement therapy and spinal surgical fixation after a motor vehicle accident in the remote past. A colonoscopy 3 years earlier identified no abnormalities, and he had not undergone prior abdominal operations. He had no history of alcohol or tobacco use. On admission, vital signs were within normal limits. Physical examination revealed marked abdominal distention, occasional high-pitched bowel sounds, tympanitic abdomen on percussion, and diffuse tenderness to palpation. No palpable masses, rebound tenderness, guarding, fluid thrill, shifting dullness, or stool in the rectal vault was found. His hernial orifices were intact. Laboratory testing revealed the following results (reference ranges provided parenthetically): hemoglobin, 13.2 g/dL (13.5-17.5 g/dL); leukocytes, 7.3 × 109/L (3.5-10.5 × 109/L); platelet count, 129 × 109/L (150-450 × 109/L); erythrocyte sedimentation rate, 8 mm/h (0-22 mm/h); C-reactive protein, 24.0 mg/L (≤8 mg/L); sodium, 140 mmol/L (135-145 mmol/L); potassium, 4.2 mmol/L (3.6-5.2 mmol/L); calcium, 8.8 mg/dL (8.9-10.1 mg/dL); magnesium, 2.2 mg/dL (1.7-2.3 mg/dL); creatinine, 0.9 mg/dL (0.8-1.3 mg/dL); and thyroid stimulating hormone, 1.3 mIU/L (0.3-5 mIU/L).1.Which one of the following is the most likely underlying etiology of abdominal distention in this patient?a.Small bowel obstruction (SBO)b.Large bowel obstructionc.Ascitesd.Adipositye.Fecal impaction Clinicians should consider the “5 F's” when evaluating patients who have abdominal distention: flatus (excess gas from bowel obstruction or pseudo-obstruction), feces (fecal impaction), fluid (ascites), fat (increased adiposity), and fetus (pregnancy in women). Patients with an acute SBO typically present with abdominal pain, nausea, and emesis.1Cheadle W.G. Garr E.E. Richardson J.D. The importance of early diagnosis of small bowel obstruction.Am Surg. 1988; 54: 565-569PubMed Google Scholar Additionally, approximately 90% of patients with SBO have had a prior abdominal procedure.1Cheadle W.G. Garr E.E. Richardson J.D. The importance of early diagnosis of small bowel obstruction.Am Surg. 1988; 54: 565-569PubMed Google Scholar In contrast, patients with a large bowel obstruction (LBO) usually present with abdominal pain, distention, and obstipation.2Sule A.Z. Ajibade A. Adult large bowel obstruction: a review of clinical experience.Ann Afr Med. 2011; 10: 45-50Crossref PubMed Scopus (14) Google Scholar Although nausea and emesis sometimes occur in LBOs, these symptoms are most commonly associated with a proximal colonic obstruction, which can have a clinical presentation similar to that of an SBO. Generally, SBOs occur with rapid onset of nausea and emesis and slower onset of constipation and abdominal distention. By contrast, LBOs occur with rapid onset of abdominal distention and obstipation, followed by a slower onset of nausea. This patient’s symptoms of abdominal pain, constipation, and distention without a history of abdominal operations were most suggestive of an LBO. Ascites is most commonly associated with abdominal distention, weight gain, early satiety, and dyspnea, secondary to abdominal fluid accumulation. Our patient had no known history of conditions associated with ascites, such as cirrhosis, nephrotic syndrome, heart failure. Moreover, no evidence of ascites was seen on physical examination. An increase in adipose tissue or fat in the abdomen can present as abdominal distention. However, adiposity typically is present in a patient with a history of obesity or metabolic syndrome, which our patient did not have. Patients with fecal impaction often have long-standing constipation, and hard stool can sometimes be detected on rectal examination. In our patient, the absence of both stool in the rectal vault and a history of long-standing constipation made this diagnosis less likely. Our patient was admitted to the hospital for further evaluation of abdominal pain and concern for obstruction. Foods and oral fluids were withheld, and intravenous fluid replacement was initiated. Given his abdominal distention and associated discomfort, a nasogastric tube was inserted, resulting in some relief of symptoms. Abdominal radiography revealed multiple loops of distended bowel located peripherally, with multiple haustra noted (small pouches caused by sacculation that give the colon its characteristic segmented appearance).2.Which one of the following is the most likely cause of this patient’s abnormal radiographic findings?a.Colorectal cancerb.Colonic volvulusc.Acute diverticulitisd.Pseudo-obstructione.Stricture The patient’s radiographic features are most consistent with an LBO, which typically includes haustra and peripherally located distended loops of bowel.3Suri S. Gupta S. Sudhakar P.J. Venkataramu N.K. Sood B. Wig J.D. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction.Acta Radiol. 1999; 40: 422-428Crossref PubMed Scopus (170) Google Scholar Radiographic findings associated with SBOs include central location of distended bowel loops and valvulae conniventes (mucosal folds of the small intestine).3Suri S. Gupta S. Sudhakar P.J. Venkataramu N.K. Sood B. Wig J.D. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction.Acta Radiol. 1999; 40: 422-428Crossref PubMed Scopus (170) Google Scholar Colorectal cancer is the most common cause of LBOs in the United States.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Carcinomas involving the rectum or left part of the colon are more likely to result in obstruction than right-sided cancers, owing to differences in colonic caliber.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Approximately 1 in 27 colorectal cancers represents an interval cancer; these neoplasms are 2.4 times more likely to arise in the proximal colon than the distal colon and more often affect patients who are older and have multiple comorbidities.5Singh S. Singh P.P. Murad M.H. Singh H. Samadder N.J. Prevalence, risk factors, and outcomes of interval colorectal cancers: a systematic review and meta-analysis.Am J Gastroenterol. 2014; 109: 1375-1389Crossref PubMed Scopus (190) Google Scholar A malignant colonic tumor is unlikely in this patient, as he had normal findings on colonoscopy 3 years earlier. Additionally, colon cancer is unlikely to be responsible for this patient’s similar symptoms 5 years earlier, especially given that he had no symptoms in the interim. Colonic volvulus accounts for 4% of LBOs in the United States.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Colonic volvulus is the most likely possibility in this clinical scenario because this patient had a similar presentation 5 years earlier that resolved spontaneously. Sigmoid volvulus accounts for approximately two-thirds of all colonic volvulus cases. Risk factors for volvulus include chronic constipation, advanced age, neuropsychiatric disorders, and medications affecting intestinal motility.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Acute diverticulitis typically presents with left lower quadrant pain, as involvement of the sigmoid colon is common, and patients usually are not constipated. Acute pseudo-obstruction is typically encountered in hospitalized patients who are severely ill or have undergone a recent surgical procedure in addition to having metabolic derangements or taking medications that impede colonic motility. Strictures usually develop in patients who have a history of inflammatory bowel disease (more prevalent in Crohn disease than ulcerative colitis), radiation therapy, diverticulosis, or colonic ischemia.3.Which one of the following is the most appropriate next step in the work-up of this patient?a.Magnetic resonance imaging (MRI) of the abdomen and pelvisb.Ultrasonography of the abdomen and pelvisc.Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast mediumd.CT of the abdomen and pelvis without IV contrast mediume.No additional testing In patients presenting with a bowel obstruction, the obstruction can be identified in 81.5% with radiography, 92.3% with CT, and 92.6% with MRI.6Matsuoka H. Takahara T. Masaki T. Sugiyama M. Hachiya J. Atomi Y. Preoperative evaluation by magnetic resonance imaging in patients with bowel obstruction.Am J Surg. 2002; 183: 614-617Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar However, the use of MRI of the abdomen and pelvis is recommended primarily for pregnant patients, children, and young adults with high levels of radiation exposure.7ACR Appropriateness CriteriaClinical Condition: Suspected Small-Bowel Obstruction.https://acsearch.acr.org/docs/69476/Narrative/Google Scholar Ultrasonography of the abdomen and pelvis is not recommended for diagnosing bowel obstruction, as identifying partial obstructions or evaluating the underlying etiology of the obstruction may be difficult.7ACR Appropriateness CriteriaClinical Condition: Suspected Small-Bowel Obstruction.https://acsearch.acr.org/docs/69476/Narrative/Google Scholar Additionally, the sensitivity of the study depends on the skills of the operator. The best imaging study for diagnosing mechanical bowel obstruction and its complications is CT.8Gore R.M. Silvers R.I. Thakrar K.H. et al.Bowel obstruction.Radiol Clin North Am. 2015; 53: 1225-1240Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar The ease and cost-effectiveness of CT make it preferable to MRI in most cases. Additionally, the American College of Radiology recommends CT of the abdomen and pelvis with IV contrast medium as the imaging study best suited to investigate suspected obstruction.7ACR Appropriateness CriteriaClinical Condition: Suspected Small-Bowel Obstruction.https://acsearch.acr.org/docs/69476/Narrative/Google Scholar A CT scan of the abdomen and pelvis without IV contrast medium should be utilized only when IV contrast medium is contraindicated. Although abdominal x-ray findings can help indicate the presence of bowel obstruction, they are insufficient to accurately confirm the diagnosis or assess for complications, such as ischemia and perforation.8Gore R.M. Silvers R.I. Thakrar K.H. et al.Bowel obstruction.Radiol Clin North Am. 2015; 53: 1225-1240Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Additional testing is necessary for further work-up of the underlying medical condition. Our patient underwent CT of the abdomen and pelvis with IV contrast medium, which revealed a sigmoid volvulus causing colonic obstruction with maximum colonic distention to 10.5 cm in the left upper quadrant of the abdomen and decompression distally.4.Which one of the following is the most appropriate next step in the treatment of this patient?a.Barium enema examinationb.Emergent laparotomyc.Nonemergent sigmoid resectiond.Endoscopic placement of colonic decompression tubee.Neostigmine therapy The goal of treatment in a stable patient with sigmoid volvulus in the acute setting is to reduce the volvulus. Barium enema examination has diagnostic and therapeutic capabilities in children; however, it is seldom utilized in the management of adults.9Mellor M.F. Drake D.G. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children.AJR Am J Roentgenol. 1994; 162: 1157-1159Crossref PubMed Scopus (48) Google Scholar Emergent laparotomy is indicated in patients who have acute complications of volvulus, such as gangrene, perforation, and peritonitis,10Atamanalp S.S. Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years.Tech Coloproctol. 2013; 17: 561-569Crossref PubMed Scopus (89) Google Scholar and when nonoperative decompression is unsuccessful. In a stable patient, sigmoid resection does not have a role in the acute setting and should be considered only after detorsion has been performed. In a patient without complications, endoscopic detorsion and decompression, followed by elective surgical treatment, are preferable. Detorsion of the colon can be accomplished via flexible sigmoidoscopy or colonoscopy and has a success rate of nearly 80%. A colonic decompression tube should be inserted after detorsion of the volvulus has been performed and should be left in place for 24 to 48 hours to allow for continued decompression and to prevent immediate recurrence.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Therefore, endoscopic placement of a colonic decompression tube is the most appropriate next step in our patient’s management.10Atamanalp S.S. Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years.Tech Coloproctol. 2013; 17: 561-569Crossref PubMed Scopus (89) Google Scholar Neostigmine may be used in cases of acute colonic pseudo-obstruction, but it is contraindicated in mechanical colonic obstruction. The colorectal surgery department was consulted for our patient, and a decision was made to decompress the bowel before surgical intervention, for reasons outlined previously. The patient underwent colonoscopy with successful endoscopic detorsion of the sigmoid colon and colonic decompression tube placement. After completion of this procedure, our patient noted substantial improvements in his abdominal pain, distention, and tenderness. He also began passing flatus. Repeated abdominal radiography after the decompression revealed persistent gaseous distention of the sigmoid colon but improvement in the distention of the colon proximal to the sigmoid volvulus.5.Which one of the following interventions is most likely to minimize occurrence of future episodes of sigmoid volvulus for this patient?a.Sigmoid resectionb.Daily fiber intakec.Extraperitonealization of sigmoid colond.Mesosigmoidoplastye.Laparoscopic-assisted endoscopic sigmoidopexy The recurrence rate of sigmoid volvulus approaches 70%, even after detorsion is successful.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar To prevent recurrent episodes of volvulus, definitive surgical treatment is performed after endoscopic detorsion and decompression have been achieved. The surgical procedure of choice is sigmoid resection, with both primary anastomosis and Hartmann procedure reported to be effective.11Kuzu M.A. Aslar A.K. Soran A. Polat A. Topcu O. Hengirmen S. Emergent resection for acute sigmoid volvulus: results of 106 consecutive cases.Dis Colon Rectum. 2002; 45: 1085-1090Crossref PubMed Scopus (67) Google Scholar Daily fiber intake would help regulate this patient’s bowel movements and minimize constipation, a known risk factor for the development of colonic volvulus. Although fiber intake would help decrease the risk of a new-onset volvulus, it would not address the anatomic abnormality associated with future recurrences once the first episode has occurred. Extraperitonealization of the sigmoid colon (a nonresectional technique that achieves fixation of the mobile sigmoid colon), mesosigmoidoplasty (a nonresectional procedure that broadens the mesosigmoid base and reduces its length), and laparoscopic-assisted endoscopic sigmoidopexy (a minimally invasive procedure that allows for visualization of the abdominal cavity while percutaneous endoscopic colostomy tubes are inserted) are safe alternatives to sigmoid resection, although only a few cases of these procedures have been described in the literature.12Bhatnagar B.N. Sharma C.L. Nonresective alternative for the cure of nongangrenous sigmoid volvulus.Dis Colon Rectum. 1998; 41: 381-388Crossref PubMed Scopus (31) Google Scholar, 13Bach O. Rudloff U. Post S. Modification of mesosigmoidoplasty for nongangrenous sigmoid volvulus.World J Surg. 2003; 27: 1329-1332Crossref PubMed Scopus (16) Google Scholar, 14Gordon-Weeks A.N. Lorenzi B. Lim J. Cristaldi M. Laparoscopic-assisted endoscopic sigmoidopexy: a new surgical option for sigmoid volvulus.Dis Colon Rectum. 2011; 54: 645-647Crossref PubMed Scopus (19) Google Scholar As a result, their use is limited to patients who are not good surgical candidates for sigmoid resection, such as the elderly. Fixation of the sigmoid colon with a percutaneous endoscopic gastrostomy tube can be used in patients with sigmoid volvulus who are not candidates for surgical intervention. A review of the outside imaging studies obtained at our patient’s presentation 5 years earlier confirmed previous sigmoid volvulus. Given that this was our patient’s second presentation of sigmoid volvulus, a decision was made to proceed with sigmoid resection. The patient completed polyethylene glycol bowel preparation with clearing of stool. Soon thereafter, a left sigmoid resection was performed with primary anastomosis and 75 cm of sigmoid colon was removed. At the time of discharge, the patient had full return to baseline bowel function and no pain. Sigmoid volvulus occurs when the sigmoid colon twists on the sigmoid mesocolon, resulting in acute, subacute, or chronic intestinal obstruction. Colonic volvulus accounts for 4% of all LBOs in the United States,4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar with sigmoid volvulus being the most common form of volvulus in the gastrointestinal tract. In areas collectively referred to as the “volvulus belt,” including parts of Africa, the Middle East, India, and Russia, colonic volvulus can account for up to 50% of all LBOs.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar The classic presentation consists of sudden onset of severe abdominal pain, emesis, and obstipation.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar Physical examination reveals marked abdominal distention. Findings such as rebound tenderness or guarding may indicate bowel ischemia from arterial occlusion or increased tension of the bowel wall.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar A CT scan of the abdomen and pelvis with IV contrast medium is the recommended imaging study in the work-up of suspected sigmoid volvulus, owing to its ease and cost-effectiveness. However, this approach may not be possible if contraindications to CT are present, such as contrast agent allergy or poor kidney function. Plain radiography can reveal a bent inner tube (double wall thickness of the inner colon and single wall thickness of the outer colon) or coffee bean sign.4Townsend C.M. Beauchamp D. Evers B.M. Mattox K. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier, Philadelphia, PA2017: 1312-1393Google Scholar An MRI of the abdomen and pelvis is recommended for pregnant patients, children, and young adults who have high levels of radiation exposure.7ACR Appropriateness CriteriaClinical Condition: Suspected Small-Bowel Obstruction.https://acsearch.acr.org/docs/69476/Narrative/Google Scholar The treatment of sigmoid volvulus in a stable patient follows a 2-step process. In the acute setting, the goal of treatment is to reduce the volvulus. Both flexible sigmoidoscopy and colonoscopy have excellent success rates in achieving detorsion and decompression of the colon.10Atamanalp S.S. Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years.Tech Coloproctol. 2013; 17: 561-569Crossref PubMed Scopus (89) Google Scholar After detorsion and decompression have been achieved, sigmoid resection is performed electively to minimize the risk of recurrence. Patients with signs of bowel necrosis are not candidates for endoscopic decompression and require emergent exploratory laparotomy.