An 80-year-old nursing home resident presents with massive abdominal distension, obstipation, and cramping. Abdominal radiograph demonstrates a large, dilated 'coffee bean' shaped loop of colon with its apex pointing toward the right upper quadrant. What is the diagnosis and initial management?

Answer and explanation

Correct answer: B. Sigmoid volvulus; initial sigmoidoscopic detorsion and decompression

  1. Step 1: Sigmoid volvulus occurs predominantly in elderly, institutionalized patients with chronic constipation and elongated sigmoid mesentery.
  2. Step 2: The classic radiographic sign is the 'coffee-bean' sign arising from the left lower quadrant and projecting to the right upper quadrant.
  3. Step 3: In the absence of peritonitis or bowel ischemia, initial management is rigid or flexible sigmoidoscopic decompression followed by elective resection.
Answer
Sigmoid volvulus; initial sigmoidoscopic detorsion and decompression.
Why not the others: 'Cecal volvulus; immediate emergency right hemicolectomy' originates in the right lower quadrant and points toward the left upper quadrant, requiring upfront operative intervention; 'Paralytic ileus; intravenous neostigmine infusion' involves generalized non-mechanical dilation; 'Acute mesenteric ischemia; mesenteric revascularization' presents with pain out of proportion to exam rather than isolated massive coffee-bean distension.

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