S1758 Coffee Bean Colon Despite Prior Left Hemicolectomy for Sigmoid Volvulus

Abstract

INTRODUCTION: Sigmoid volvulus (SV) is a relatively uncommon cause of intestinal obstruction in the United States, accounting for less than 10% of cases. Initial management includes endoscopic reduction of the SV, however recurrent volvulus is an indication for surgical repair. We present an uncommon case of recurrent SV in a patient who had a prior left hemicolectomy for SV. CASE DESCRIPTION/METHODS: A 53 year old female with a history of neurocognitive delay and SV status-post left hemicolectomy presented to clinic with abdominal distention and non productive cough for two weeks. Chest X-ray revealed elevated right hemidiaphragm likely due to markedly distended colon with typical “coffee bean” sign without signs of acute respiratory consolidation. Given her history of SV, she was admitted for further work up to rule out obstruction. CT Abdomen revealed severely dilated loops of colon up to 14.2 cm with an abrupt transition of normal caliber in the distal sigmoid colon at the sigmoid flexure. Bowel decompression via nasogastric tube was not possible due to patient intolerance with placement. She was passing flatus and denied abdominal pain so tube decompression was held while awaiting colonoscopy. Colonoscopy performed the next day demonstrated grossly dilated colonic lumen obscuring internal markings. Colonic decompression was performed with improvement in abdominal distension. While the internal colonic markings were difficult to visualize due to distention, no ischemia was noted. Repeat abdominal x-ray showed decreased bowel distention. The patient tolerated oral intake and had a bowel movement and flatus the next day. She was discharged home with plans for outpatient follow up for a repeat colonoscopy. DISCUSSION: Sigmoid volvulus accounts for approximately 8% of intestinal obstructions, behind malignancy and diverticulitis. The coffee bean sign is a classic radiographic finding of SV. When complicated with gangrene or perforation, surgery is the definitive intervention. Recurrence after initial endoscopic treatment can occur in up to 60% of patients. Our patient had a recurrent episode despite prior surgical management. To the best of our knowledge, there have been no reported cases of colonic obstruction resulting in the coffee bean sign in a patient who is status post left hemicolectomy for a prior SV. It is important to keep this in the differential when evaluating patients who have previously received surgical treatment of SV, especially in a patient with neurocognitive delay who cannot communicate.Figure 1.: Abdominal radiograph revealing severe colonic distension consistent with “coffee bean sign.”Figure 2.: Abdominal CT Scan with severe colonic distension of 14.2 cm.