Emergency Medicine Case Presentation

James Park MSIV

April 14, 2006

Chief Complaint

• A 72 year old Caucasian gentleman presents to Christ ED with complaint of abdominal pain.

History of Chief Complaint

• Six day history of increasing abdominal pain in LLQ.

• Pain is dull and constant with N/V.

• No bowel movements or flatus for the past six days.

• Increasing abdominal distention with lack of appetite.

History (Cont)

• He had a similar type of problem a couple of months ago at Illinois Masonic Hospital. Impacted at that time and underwent endoscopic evaluation. Reportedly unremarkable.

• Over the past several days he has tried laxatives and enemas. Did not relieve his obstipation.

History (Cont)

• PMH: None except for a recent colon impaction.• PSH: None• Allergies: NKDA• Medications: None• Family History: Noncontributory• Social History: Patient lives by himself. Smokes

half-a-pack for 50 years. Ocassional EtOH. Denies other drug use.

Review of Systems

• GENERAL – Loss of 2 lbs over past week. Episodes of fever/chills

• HEENT – Denies trauma, changes in vision, hearing.

• CARDIAC – Denies chest pain, palpitations

• PULMONARY – Denies chronic cough and SOB.

• GI – As per HPI. No hematochezia/melena

• GU – Denies dysuria, polyuria, hematuria.

• Musculoskeletal – Denies arthralgias/myalgias.

• NEURO – Denies paresthesias. CN II-XII grossly intact.

• ENDOCRINE – Denies hot or cold intolerance.

Physical Examination

• Vitals: 96.8, 102 pulse, 26 resp, 145/87, 94% RA

• General: Well developed, but cachectic appearing.

• HEENT: PERRLA, EOMI, mucus membranes moist, no cervical LAD

• CARDIO: RRR, no M/R/G• PULMONARY: CTAB

Physical Examination

• ABD: Soft, but significantly detected. LLQ and periumbilical tenderness w/o G/R/R. Hyperactive/tympanic bowel sounds. Rectal exam revealed good rectal tone. Heme-Occult neg.

• EXT: No C/C/E.• NEURO: A & O x 4. CN II-XII grossly intact.

Laboratory Data

• WBC 7.7

• Hgb 15.2

• Hct 43.9

• Platelets 417,000

• Na 138

• K 2.8

• Cl 95

• CO2 30

• BUN 40

• Creatinine 1.1

• Glucose 103

• Bilirubin 2.0

• AST 36

• ALT 47

• Alk Phos 92

• Lipase 165

• U/A is + for ketones and protein, but otherwise -

Differential Diagnosis

Differential Diagnosis

• Colon cancer• Volvulus• Diverticular disease• Extrinsic compression

from metastatic carcinoma

• Hernia• Intussusception

• Fecal impaction• Paralytic ileus• Toxic megacolon

Abdominal X-Ray

•

Volvulus

-Rotation of a segment of bowel around its mesenteric axis that is sufficient to cause a complete or partial obstruction of the lumen and a variable degree of impairment to its vascular supply.

-Can only occur if the two ends of the segment that are twisted are in close approximation

-this occurs in the sigmoid colon (60%) and the cecum (40%) in the large bowel

Volvulus

-Accounts for 10-13% of all large bowel obstructions in the U.S.

-incidence is roughly 3 per 100,000 in the U.S.

-responsible for approximately 5% of large bowel

obstructions

Patient Population

• Occurs most commonly in patients with severe neurological and psychiatric dx and in elderly patients with debilitating dx who are inactive– Intestinal motility

• Uncommon in people who are active

Pathophysiology of Obstruction

• With mechanical obstruction, air and fluid accumulate in the bowel lumen. Results in increase of intestinal intraluminal pressure.

• This further inhibits absorption and stimulates influx of water and electrolytes into lumen.

• Initially, there is increase in peristaltic activity. But as process progresses, coordinated peristaltic activity diminishes along with contractile function.

Pathophysiology of Obstruction

• Gives rise to dilated and atonic bowel proximal to point of obstruction.

• With progression, patient may actually appear to improve clinically with less frequent and crampy pain.

• Effect of mechanical obstruction causes an initial increase in blood flow.

• With unrelieved obstruction, blood flow diminishes leading to breakdown of mucosal barriers and increased susceptibility to bacterial invasion and ischemia.

Sigmoid Volvulus:Common Patient Symptoms

• Usual history: severe, chronic constipation

– Constipation leads to decrease in function in the colon particularly in the sigmoid region producing a sigmoid loop which is attached by a narrow mesenteric root

• Early symptoms

– Intermittent cramping

– lower abdominal pain

– Progressive abdominal distention

Symptoms

• Later symptoms

– N/V

– Dehydration

– Obstipation

Many patients have a history of similar episodes that

resolved in the passage of a great amount of flatus and

stool which resolved all symptoms

Physical Examination

• Diffuse abdominal tenderness

• Tympanic abdominal sounds

• Respiratory compromise – elevation of diaphragm

*Fever, severe abdominal tenderness and peritonitis suggest

strangulation

*Perforation is not common because the sigmoid colon in

older patients is usually thickened

http://images.google.com/imgres?imgurl=http://www.hawaii.edu/medicine/pediatrics/pemxray/v2c08l.jpg&imgrefurl=http://www.hawaii.edu/medicine/pediatrics/pemxray/v2c08.html&h=578&w=376&sz=22&tbnid=rJFuu_TnKr8J:&tbnh=132&tbnw=85&hl=en&start=3&prev=/images%3Fq%3Dvolvulus%2Bsigmoid%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG

Diagnosis

• Volvulus should be included in the differential diagnosis

of any acute abdomen

• Volvulus can be confirmed in 80% by a plain-film

of the abdomen

-shows a very dilated single loop of colon in the left

abdomen with both ends toward the pelvis and the

center superiorly positioned – looking like

a “bent innertube”

Plain-film radiographof abdomen

Diagnosis

• Barium enema– Bird’s beak or Ace of Spades – Pathognomonic of volvulus

“bird’s beak” on barium enema

CT Scan

• Mesocolon “whirl” sign around the SMA is pathognomonic of volvulus on CT

Mesocolon Whirl

                              

Labs

• Increased WBCs 20,000 – 25,000/mm³ with

polymorphonuclear predominance suggests strangulation

Management

• Surgery consult

• Treatment of choice for nonstrangulated sigmoid volvulus

is hydrostatic decompression and detorsion with colopexy

-accomplished through a sigmoidscope using a rectal

tube

-success in 85%-95%

• Rectal tube should be taped to thigh and left 1-2 days to allow decompression and to prevent recurrence

• Followed by cathartics and complete colonoscopy

Management

• If rectal tube is ineffective, barium enema may be considered as treatment

• If decompression is ineffective or if strangulation is present, emergent surgery is indicated to reduce the

volvulus

• Laparotomy with resection of sigmoid colon– Hartmann’s operation

Management

• Even if nonoperative decompression is effective, recurrence occurs in almost 90% of patients

• Elective resection is often indicated after the first episode

of sigmoid volvulus

Cecal Volvulus

• Most common in ages 25-35

• Hypofixation (congenital) of the cecum, proximal ascending colon and terminal ileum to the posterior abdominal wall is a prerequisite. Marathon runners may be predisposed to developing cecal volvulus.

• Rotation of the cecum is usually 360° around the mesenteric pedicle of the ileocecal artery

• Cecum folds cephalad out over a fixed ascending colon

• Study on cadavers found that 11-22% of population has hypofixation of the colon sufficient to cause volvulus

Cecal Volvulus

• Causes intermittent episodes of obstruction that is spontaneously relieved as cecum falls back into normal position

• Often preceded by abdominal surgery with the potential of disturbing the fixation of the cecum to the posterior abdominal wall

• Pregnancy, malrotation, and obstructive lesions of the colon also predispose to volvulus

Diagnosis

• Acute, severe abdominal pain followed by N/V

• Abdomen usually very tender and distended

• Plain-film of abdomen usually shows one, large oval segment of colon in the central abdomen with distended small bowel loops and an empty distal large bowel

• Cecum usually displaced to left side of abdomen, making a gas-filled comma shape

Cecal Volvulus on plain-film“coffee-bean deformity”

Cecal Volvulus

• Management is usually surgical – right colectomy

• Nonoperative decompression is usually unsuccessful

References

• Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc

• http://home.mdconsult.com/das/book/51206360-2/view/999?sid=411818119

• Townsend, C.M., Sabiston’s Textbook of Surgery. Elsevier. 17th edition. 2004.