RESIDENTS’ CLINIC
RESIDENTS’ CLINIC
83-Year-Old Woman With Abdominal Distention and Constipation
Mohammad Albaba, MD,* and Paul Y. Takahashi, MD†
A n 83-year-old woman with Alzheimer dementia pre-
sented to the emergency department with abdominal
distention. Her husband provided the history. After having
constipation for 1 week, she developed a progressively dis-
tended abdomen in the course of 2 days, with anorexia but
no vomiting, melena, or hematochezia. She had no history
of fever, rigors, dyspnea, or weight loss. Her medical his-
tory was remarkable for hypertension, coronary artery dis-
ease, and impaired fasting blood glucose levels. Despite the
recent symptoms, she had no history of gastroenterologic
symptoms, cancer, abdominal surgeries, or colon screen-
ing studies. She lived with her husband in the community
and was dependent on him for her activities of daily living
except for ambulation with a walker and feeding herself.
She was a nonsmoker and nondrinker. Her medications
were 60 mg/d of isosorbide mononitrate, 325 mg/d of as-
pirin, 2.5 mg/d of amlodipine, 20 mg/d of atorvastatin, and
a combination of 37.5 mg/d of triamterene and 25 mg/d of
hydrochlorothiazide.
On examination, the patient appeared to be in mild dis-
tress with abdominal distention. Her vital signs were as fol-
lows: temperature, 36.6ºC; blood pressure, 154/89 mm Hg;
regular pulse, 84 beats/min; respiration rate, 20 breaths/
min; and oxygen saturation, 94% while breathing room air.
Abdominal examination revealed marked distention with
diminished bowel sounds and moderate discomfort with
deep palpation of the left lower quadrant, but no peritoneal
irritation signs, Murphy sign, McBurney point tenderness,
abdominal bruit, ascites, hepatosplenomegaly, or palpable
mass. Rectal examination revealed no stool in the vault and
no obvious mass.
The patient had normal levels of hemoglobin, white
blood cells, platelets, chloride, bicarbonate, creatinine,
blood urea nitrogen, troponin, and lipase, as well as a pro-
thrombin time within the normal range. She had a serum so-
dium of 126 mEq/L (reference ranges provided parentheti-
cally) (135-145 mEq/L), a potassium level of 2.5 mmol/L
(3.6-4.8 mmol/L), and a blood glucose level of 198 mg/
dL (70-100 mg/dL). Urinalysis was positive for trace oc-
*Fellow in Geriatrics, Mayo School of Graduate Medical Education, Mayo
Clinic, Rochester, MN.
†Adviser to fellow and Consultant in Primary Care Internal Medicine, Mayo
Clinic, Rochester, MN.
See end of article for correct answers to questions.
Individual reprints of this article are not available. Address correspondence to
Paul Y. Takahashi, MD, Division of Primary Care Internal Medicine, Mayo Clinic,
200 First St SW, Rochester, MN 55905 (takahashi.paul@mayo.edu).
© 2009 Mayo Foundation for Medical Education and Research
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cult blood and 1+ protein. Abdominal plain radiography
showed prominent gaseous dilatation of the transverse co-
lon and redundant sigmoid colon without distinct signs of
obstruction or free air.
1. Which one of the following is the most likely cause of
the abdominal distention in this patient?
a. Acute diverticulitis with secondary ileus
b. Ileus secondary to acute pyelonephritis
c. Acute pancreatitis with associated ileus
d. Obstructing colon cancer
e. Pseudoobstruction of the colon secondary to electrolyte
derangement and constipation
Diverticular disease is commonly encountered in older
adults, who often present with abdominal pain of several
days’ duration, low-grade fever, and mild leukocytosis.
Patients often have symptoms of constipation, abdominal
distention, nausea, and/or vomiting.1 Acute diverticulitis
was an unlikely diagnosis in our patient who had no fever
or leukocytosis.
Acute pyelonephritis usually presents with fever and py­
uria and may be characterized by gastrointestinal symptoms,
such as abdominal pain, anorexia, and/or ileus. Patients
frequently describe flank pain as well as urinary frequency.
The results of our patient’s urinalysis and the lack of urinary
symptoms made acute pyelonephritis unlikely.
Patients with acute pancreatitis experience severe ab-
dominal pain, nausea, and vomiting. With severe inflamma-
tion of the abdomen, acute pancreatitis might be associated
with ileus. Biochemically, most patients have an elevated
lipase and/or amylase level. Our patient did not report se-
vere abdominal pain. Her lipase values were within normal
range, making acute pancreatitis unlikely.
The risk of colon cancer increases with advanced age;
thus, cancer is always a concern. Clinically, patients with co-
lon cancer often have changes in bowel habits, hematochezia,
abdominal pain, and/or iron deficiency anemia. Colon cancer
obstruction usually follows a period of worsening symptoms
of partial obstruction, such as abdominal distention, pain,
and constipation. Our patient had no melena, hematochezia,
anemia, or symptoms of progressive colon obstruction. Ob-
structing malignancy was an unlikely diagnosis.
Pseudoobstruction of the colon is defined as substantial
colonic distention in the absence of an obstructing lesion.
Patients usually present with abdominal distention and pain
associated with constipation, nausea, and vomiting. Colon
pseudoobstruction is often associated with other illnesses.
• doi:10.4065/mcp.2008.0450 • www.mayoclinicproceedings.com
 RESIDENTS’ CLINIC

Metabolic imbalance and especially hypokalemia are very

common in patients with colon pseudoobstruction; how-
ever, in most cases other factors are also at work.2 Other
common possible underlying etiologies for pseudoobstruc-
tion of the colon are severe infection, trauma, shock, and
recent surgery. Our patient had severe hypokalemia asso-
ciated with constipation and poor oral intake, which was
thought to have caused colon pseudoobstruction.
The patient was hospitalized and hydrated with intrave-
nous saline with potassium supplementation. Four days lat-
er, she had a potassium level of 4.5 mmol/L and a sodium
level in the normal range. She received repeated enemas
and rectal bisacodyl. These measures were unsuccessful,
and her abdomen became more distended. Her repeated
upright abdominal radiograph is shown in the Figure.
2. Which one of the following is the most likely diagno-
sis on the basis of the new radiologic findings and the
poor response to previous management?
a. Toxic megacolon
b. Sigmoid volvulus
c. Diabetic gastroparesis
d. Severe constipation
e. Bowel perforation
Patients with toxic megacolon usually present with FIGURE. Upright abdominal radiographs on hospitalization day 4.
bloody diarrhea of several days’ duration, followed by fe-
ver, tachycardia, and hypotension. Toxic megacolon is a
of stool. Abdominal radiography shows substantial accu-
potentially fatal complication of inflammatory, infectious,
mulation of fecal material and might show colonic dilata-
or ischemic colitis that is characterized by severe segmen-
tion. No stool was revealed in the rectal examination of our
tal or total nonobstructive dilatation of the colon. On plain
patient. Her abdominal radiograph showed an extensive
radiography, dilatation involves primarily the proximal and
gaseous dilatation of the colon and “a bent inner-tube ap-
only rarely the sigmoid colon.3 Our patient had no signs
pearance”10 of the sigmoid, without any remarkable stool
of shock. Her radiograph revealed severe dilatation of the
buildup. Severe constipation and fecal impaction were un-
sigmoid colon. Given the clinical and radiologic findings,
likely diagnoses.
toxic megacolon was unlikely.
Patients with bowel perforation often have severe ab-
Sigmoid volvulus presents with severe abdominal dis-
dominal pain, guarding, and potentially rebound tender-
tention and colon obstruction in older, debilitated adults.
ness. Radiography will often show free air in the upright
On plain radiography, the colon appears severely distend-
or left lateral position. As our patient did not have such a
ed, and the dilated sigmoid forms an ahaustral loop in the
clinical presentation and had no free air in the abdomen,
shape of an “omega sign.”4 Because of obstruction at the
bowel perforation was unlikely.
sigmoid level, radiography usually reveals gas paucity in
On the basis of findings on abdominal radiography, we
the rectum.4 Our patient’s radiographic findings were con-
concluded this was a sigmoid volvulus and initiated a man-
sistent with sigmoid volvulus.
agement plan.
Gastroparesis is a chronic condition characterized by a
delay in stomach emptying, which leads to periodic symp- 3. Given the patient’s diagnosis, which one of the following
toms of nausea, vomiting, and abdominal discomfort, as is the most appropriate next step in her management?
well as marked gastric dilation on radiography. Because a. Conservative management with intravenous hydration,
our patient’s radiograph did not show gastric dilation, gas- bowel rest, and watchful observation
troparesis was unlikely. b. Urgent surgical resection of the sigmoid colon
Severe chronic constipation might present with abdomi- c. Laparoscopic resection of the sigmoid colon
nal pain and distention. Fecal impaction can cause colonic d. Endoscopic reduction of the sigmoid volvulus
obstruction. Rectal examination may reveal large amounts e. Intravenous antibiotics

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a Clinic Proceedings.
RESIDENTS’ CLINIC
In sigmoid volvulus, the blood supply to the involved
gut is compromised. The bowel may become gangrenous,
leading to perforation, peritonitis, and potentially fatal sep-
sis. Immediate detorsion is required with volvulus to re-
store the compromised blood perfusion.
Conservative management with rehydration and bowel
rest will not release the volvulus and restore blood flow to
the sigmoid and is therefore inappropriate. Surgical resec-
tion of sigmoid colon does not meet initial treatment goals
of relieving the volvulus and restoring blood perfusion.
For patients who have developed irreversible ischemic
bowel injury, resection of the affected colon may become
a life-saving procedure. The clinical and biochemical find-
ings made bowel gangrene unlikely in our patient. There-
fore, neither open surgical nor laparoscopic resection was
indicated.
Endoscopic reduction of the volvulus relieves the obstruc-
tion and restores the blood supply to the affected sigmoid.
Once sigmoid volvulus is suspected, endoscopic reduction
should be performed immediately, before the volvulus bow-
el sustains irreversible ischemic injury. During endoscopy,
the clinician can also visualize the colon and determine if the
patient has developed bowel ischemia.5 Endoscopic reduc-
tion of the sigmoid volvulus was the most appropriate next
step in the management of our patient.
Intravenous antibiotics are an important adjunctive
treatment in patients with peritonitis. Because our patient
had no signs of abdominal infection and the primary goal
was to restore adequate blood flow to the bowel, antibiotic
therapy was inappropriate.
Our patient underwent colonoscopy, which revealed an
apparent volvulus at the rectosigmoid junction. By gently
twisting and advancing the scope, we reduced the volvulus
and passed the scope into a dilated sigmoid. Inspection of
the colon revealed no other lesions or ischemia. A decom-
pression tube was left in the colon.
4. Which one of the following statements regarding this
patient’s condition is true?
a. The patient’s children have a high risk of developing
sigmoid volvulus
b. Sigmoid volvulus is a risk factor for developing colon
cancer
c. Sigmoid volvulus is usually associated with mitral
regurgitation
d. After endoscopic reduction alone, future recurrence of
sigmoid volvulus is rare
e. After successful endoscopic reduction, the sigmoid co-
lon should be resected
No genetic factors are known to increase the risk of hav-
ing sigmoid volvulus, and therefore children would not be
at increased risk. Although a few cases of combined vol-
1128 Mayo Clin Proc. • December 2009;84(12):1126-1129
For personal use. Mass reproduce only with permission from Mayo
vulus and cancer of the sigmoid have been reported, no
clear causal relationship exists between the 2 entities. No
association is known between sigmoid volvulus and mitral
regurgitation.
Recurrence of sigmoid volvulus is very common. After
endoscopic reduction alone, the recurrence rate can be more
than 50%.6 Risk factors that predict recurrence have not been
established. After performing the endoscopic reduction and
decompressing the obstructed colon, a surgical correction of
the underlying anatomy is needed to prevent volvulus recur-
rence. One randomized trial suggests performing Hartmann
operation (resection of the sigmoid with closing of the rectal
stump and colostomy) for patients who develop gangrenous
sigmoid. If the reduced bowel is not ischemic, the sigmoid
colon could be resected with primary anastomosis. Mesosig-
moidopexy (surgical repair and fixation of the mesentery of
the sigmoid flexure) is less successful than resection of the
sigmoid colon.7 In selected patients, qualified surgeons can
perform sigmoid resection laparoscopically.
The hospital team discussed the findings of the colonos-
copy with the patient’s family. The physician explained
the likelihood of recurrence and the different procedures
that may prevent future volvulus. Because of the patient’s
impaired cognitive and functional status, her husband re-
quested conservative management. He elected not to pro-
ceed with any further operative procedure. The patient re-
covered gradually, and the colonic decompression tube was
removed. She was discharged to her home.
Three months later the patient was seen in the emergen-
cy department with a presentation similar to that of her pre-
vious admission. Emergency colonoscopy was performed.
Unfortunately, it revealed recurrent sigmoid volvulus with
necrotic bowel.
5. Which one of the following is the most appropriate
next step during this admission?
a. Arrange for a care conference with patient’s family and
power of attorney immediately to discuss findings, prog-
nosis, patient’s wishes, and plan of care
b. Because of advanced age, functional decline, and de-
mentia, patient should receive hospice and comfort care
only
c. Start broad-coverage intravenous antibiotics and fluid
resuscitation; refer patient for emergency surgical re-
section of the necrotic bowel
d. Initiate intravenous antibiotics
e. Perform laparoscopic sigmoidectomy
The 4 basic tenets of medical ethics are beneficence (act
in the best interest of the patient), nonmaleficence (do no
harm), autonomy (patients have the right to choose or re-
fuse treatment), and justice (health care resources should
be equitably distributed).
• doi:10.4065/mcp.2008.0450 • www.mayoclinicproceedings.com
a Clinic Proceedings.

The clinician should explain clinical findings, diagnosis,
and prognosis to the patient and family (when permitted by
a competent patient) in all situations. This principle par-
ticularly applies when one faces a serious or life-threaten-
ing situation. All reasonable approaches and their potential
risks and benefits should be discussed with the patient and
family. The health care professional should help the fam-
ily, with the patient’s input, choose the approach that best
meets the patient’s wishes (shared decision making). In our
case, the family made decisions given the cognitive status
of the patient. Arranging for a care conference with the pa-
tient’s family would be the most appropriate next step.
Although the patient had a poor prognosis and a high
risk of perioperative complications because of her ad-
vanced age and poor functional status,8,9 comfort care alone
would have been inappropriate without discussing the find-
ings and the different management options with her fam-
ily. If the family is available, proceeding to surgery and
intravenous antibiotics would be inappropriate without
conducting the appropriate discussion and making shared
decisions.
Antibiotic treatment without fluid resuscitation and sur-
gical removal of the gangrenous bowel is futile and there-
fore inappropriate. Proceeding to laparoscopic sigmoidec-
tomy would also be inappropriate without the consent of
the family.
After discussing the findings and prognosis, the family
requested comfort care only. The patient entered hospice
care and died within 24 hours.
DISCUSSION
Sigmoid volvulus is a common and potentially life-threat-
ening condition occurring in older, frail adults. A volvulus
of the colon occurs in the sigmoid region about 40% of
the time.10 Patients usually have symptoms of continuous
abdominal pain, distention, nausea, and constipation. Of-
ten vomiting does not occur or occurs infrequently. These
symptoms often seem nonspecific and are even less spe-
cific in patients unable to verbalize symptoms. On plain
radiography, “bent inner-tube appearance” (severely dis-
tended sigmoid loop) is the classic finding. Some authors
describe the dilated twisted sigmoid loop as an “inverted
Mayo Clin Proc. • December 2009;84(12):1126-1129
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RESIDENTS’ CLINIC
U” or “omega sign.”4 Clinicians often observe a lack of
gas in the rectum distal to the obstruction and dilated de-
scending colon.4 Typical computed tomographic findings
include a “bird-beak appearance” and a “whirl pattern” of
the dilated twisted sigmoid.4
The appropriate management should relieve the volvu-
lus, reestablish the blood perfusion to the affected colon,
and prevent possible future recurrence. The presence of
gangrenous bowel is a major predictor of mortality. Endo-
scopic reduction of sigmoid volvulus alone is associated
with a significant risk of recurrence; hence, sigmoid resec-
tion with coloproctostomy or end colostomy should follow
endoscopic decompression. Laparoscopic sigmoidectomy
minimizes surgical complications and shortens recovery
time.11 It provides a promising alternative for elderly pa-
tients with chronic illness.
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operative complications and length of stay in patients undergoing noncardiac
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9. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tol-
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Correct answers: 1. e, 2. b, 3. d, 4. e, 5. a
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