Frail patient with abdominal pain.

Volvulus is a frequent condition in patients presenting in the emergency department (ED) with abdominal pain. While cecal volvulus occurs more often in young patients, sigmoid volvulus is more common in elderly patients.

A 76-year-old man presented with abdominal pain and constipation. A previous ischemic stroke and subsequent neurological complications had left him bedridden for six years. Surgical history included tracheotomy and gastrostomy tube. On admission he was normotensive and afebrile but mildly tachycardic. Abdominal examination revealed severe distension and tenderness in the left lower quadrant with localized peritonitis. Laboratory tests yielded leukocytosis. Abdominal radiographs and computed tomography (CT) revealed a markedly dilated sigmoid colon in the presence of distal volvulus. (Figures 1 and 2) With clinical and laboratory signs suggestive of gangrene, the patient underwent open laparotomy. Sigmoid volvulus with necrotic bowel was detected; reduction of the volvulus and sigmoid resection was performed. No surgical complication occurred, but he ultimately succumbed to pulmonary complications.

Figure 1.

Abdominal radiograph

Figure 2.

Anteroposterior scout film of computed tomography abdomen

Volvulus is a common condition in patients presenting with abdominal pain. Cecal volvulus occurs more often in young patients, while sigmoid volvulus is more common in the elderly. Being bedridden, neuropsychiatric conditions and chronic constipation are common risk factors for sigmoid bowel involvement. Typical radiographs and CT findings include distended sigmoid loops with an inverted “U” shape and/or coffee-bean appearance (Figure 1 and 2). However, classic appearance is absent in one fourth of CT scans.2 Treatment requires detorsion of sigmoid loops. Endoscopic reduction is effective in most cases; however, recurrence is common. Surgical approach is indicated in suspected gangrene, perforation and for patients with recurrent volvulus.

The increasing access of elderly and frail patients in emergency departments entails an increase in diagnosis of sigmoid volvulus, raising clinical and ethical questions about appropriate treatment.3