Large Bowel Obstruction (LBO): The Daily PANCE Blueprint
An 85-year-old nursing home resident is brought to the emergency department due to 2 days of worsening abdominal pain and distension. He has had multiple episodes of vomiting and has not passed stool for 3 days. The patient has a history of Parkinson's disease, hypertension, and chronic constipation. He has had no prior abdominal surgery. Temperature is 37.5°C (99.5°F), blood pressure is 130/85 mm Hg, and pulse is 88/min. Physical examination reveals a distended and tympanic abdomen with tenderness to palpation but no peritoneal signs. Bowel sounds are high-pitched and increased. Rectal examination reveals an empty rectum. Abdominal radiography shows a distended loop of bowel with a coffee bean sign. What is the most likely cause of this patient’s abdominal pain?
A. Small bowel obstruction
B. Diverticulitis
C. Sigmoid volvulus
D. Large bowel obstruction due to malignancy
E. Mesenteric ischemia
The answer is C. Sigmoid volvulus
Sigmoid volvulus is the most likely cause of this patient’s abdominal pain, given his history of chronic constipation and the radiographic finding of a distended loop of bowel with a coffee bean sign. Sigmoid volvulus occurs when a loop of the sigmoid colon twists around its mesenteric attachment, leading to obstruction and potentially ischemia if not promptly treated. It is more common in elderly individuals and those with a history of chronic constipation.
"The “coffee bean sign” is a radiologic finding seen on abdominal X-rays and is associated with sigmoid volvulus. It appears as a large, dilated loop of the sigmoid colon, which resembles a coffee bean due to the twisted configuration. This sign is helpful in diagnosing sigmoid volvulus, indicating that the sigmoid colon has twisted on itself, leading to obstruction."
- A. Small bowel obstruction: Small bowel obstruction typically presents with central abdominal pain, vomiting, and distension. Radiographs often show multiple air-fluid levels and dilated loops of small intestine. The coffee bean sign is not associated with small bowel obstruction.
- B. Diverticulitis: Diverticulitis often presents with lower left quadrant pain, fever, and leukocytosis. It does not typically cause the radiographic appearance described and is less likely to cause complete bowel obstruction.
- D. Large bowel obstruction due to malignancy: Large bowel obstruction due to malignancy can cause similar symptoms, but the radiographic finding of a coffee bean sign is characteristic of sigmoid volvulus. Additionally, malignancy-related obstructions are more likely to present with a gradual onset of symptoms.
- E. Mesenteric ischemia: Mesenteric ischemia typically presents with severe abdominal pain out of proportion to physical findings, often in patients with cardiovascular risk factors. It does not present with the coffee bean sign on radiography and is less likely to cause a complete bowel obstruction with distension as described.
Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Colorectal disorders ⇒ Large Bowel Obstruction