Abdomen Case #6

80 y/o white male presents c/o acute onset of severe abdominal pain, abdominal distention, and constipation. He notes that he has had occasional episodes of severe pain in LLQ similar to this but have resolved on there own. Patient has a history of chronic constipation.

History & PhysicalT: 99.0 P 100 R 16 BP 120/80Gen: appears to be in pain, HEENT: PERRL, NCAT, oropharnyx clearCV: RRR, no, m/r/gPulm: CTABAbd: TTP diffusely worse in LLQ; distended abdomen Left side > Right side; tympanic abdomen to percussionExt: 2+ pulse, no c/c/e

Abdominal X-Ray

Abdominal X-Ray•Coffee Bean Sign:• As closed loop of bowel

distends with gas, walls dilate, causing coffee bean like appearance.

•Lose Haustral Markings•Cleft • Arises from Left Pelvis and

points towards RUQ (usually)

•Additional Findings in Sigmoid Volvulus (Not seen Here)• Left Flank Overlap Sign• Northern Exposure Sign

Additional Findings in Sigmoid Volvulus

Left Flank Overlap Sign:Dilated Sigmoid

Colon overlaps Descending Colon

Can see descending colon behind dilated bowel.

Northern Exposure Sign:Dilated Sigmoid

Colon reaches superiorly to Transverse Colon.

IV & IV FluidsAnalgesics & AntiemeticsNG tube decompressionSurgical ConsultReduction with endoscopy can by 85-95%

successful but has a 60% recurrence rate.Sigmoid Resection is definitive treatment

ED Management

Commonly seen in elderly patients with history of chronic constipation, often neurologically debilitated.

Complications: Colonic Ischemia, Perforation, Peritonitis, Sepsis

Pearls

Feldman, Deborah. “The Coffee Bean Sign” Radiology http://radiology.rsna.org/content/216/1/178.full

www.diagnosticimaging.com/display/article/113619/1410628

http://www.learningradiology.com/notes/ginotes/sigmoidvolvpage.htm

Schwartz, David. Emergency Radiology. 2000. pg 527-529.

Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter 79 Intestinal Obstruction

References