An 80-year-old nursing home resident presents with marked abdominal distention, obstipation, and cramping lower abdominal pain. Plain radiograph reveals a dilated, ahaustral, U-shaped colonic loop arising from the pelvis and pointing to the right upper quadrant ('coffee-bean' sign). What is the initial intervention of choice if there are no signs of peritonitis or bowel necrosis?

Answer and explanation

Correct answer: D. Rigid or flexible sigmoidoscopy for endoscopic detorsion and rectal tube placement

  1. Step 1: The clinical scenario and radiographic 'coffee-bean' sign are diagnostic of acute sigmoid volvulus.
  2. Step 2: In stable patients without peritonitis, bowel gangrene, or perforation, the initial treatment of choice is endoscopic decompression and detorsion using rigid or flexible sigmoidoscopy, followed by placement of a rectal tube.
  3. Step 3: Elective resection is planned later due to high recurrence rates.
Answer
Rigid or flexible sigmoidoscopy for endoscopic detorsion and rectal tube placement.
Why not the others: 'Immediate open total proctocolectomy' is excessive surgical morbidity for uncomplicated sigmoid volvulus; 'Emergency Hartmann's procedure' is reserved for patients with bowel gangrene, perforation, or failed endoscopic detorsion; 'High-dose oral laxatives' are contraindicated in mechanical obstruction and risk perforation.

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