Diagnosis: Sigmoid Volvulus

The patient's KUB revealed a large loop of dilated colon measuring up to 13.4 cm in diameter pointing towards the left upper quadrant. Gas is also seen throughout the entire colon.

A CT scan of his abdomen and pelvis similarly showed diffuse dilatation of large bowel loops up to 11 cm with bowel dilatation extending down to the upper pelvis where there is an abrupt narrowing of sigmoid colon and a whirl sign, consistent with sigmoid volvulus. 

Colorectal surgery was urgently consulted and the patient underwent sigmoidoscopy with failure of the scope to pass the obstruction or decompress the bowel. The gastrointestinal service was then consulted and the patient underwent a colonoscopy in which the patient's cecum was reached by the endoscope however the procedure also failed to decompress the bowel.

The patient was then taken to the OR by colorectal surgery for laparoscopic resection of the sigmoid colon and imobilization of the splenic flexure. The patient did well post-operatively and was discharged from the hospital 2 days later. 

Volvulus: when a loop of bowel twists and obstructs the intestinal lumen; if severe enough may compromise vascular supply to the colon

Epidemiology

• more common in older adults with mean age 60 to 70 years, however all age groups are affected
• most common portions of bowel involved  are the sigmoid colon and cecum  occurring at roughly equal frequency

Presentation

• Hallmark of sigmoid volvulus is a triad of abdominal pain, distention, and constipation
• Distended tympanic abdomen on exam
• Onset may be acute or insidious with many days before discovery
• Severe pain, absent bowel sounds, and cardiovascular instability should prompt concern for gangrenous bowel 

Workup

• Diagnosis is made by plain radiographs in most cases 
• CT and sigmoidoscopy both are highly accurate at making the diagnosis

Management

• If clinical evidence of gangrenous bowel is absent (minimal pain, stable vital signs) then endoscopic detorsion by an experienced operator can be attempted
• successful in 50-90% cases  
• If gangrenous bowel identified on endoscopy, or endoscopic decompression unsuccessful --> surgical management is indicated

Disposition and Outcome

• All patients with volvulus require hospitalization for intervention
• Rate of recurrence estimated to be as high as 60%! - Therefore elective surgical resection of redundant sigmoid colon is recommended
• Mortality rate:
• Overall - 20%
• Patients with gangrene - 50% 

References: 

Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 95: Disorders of the Large Intestine by Michael A. Peterson

Bad Cramps

A 41 year-old male with no past medical history presents to the emergency department with chief complaint of mid abdominal pain and non-bloody diarrhea since last night. The patient describes his pain as intermittent and crampy with a mild cough. He tried taking Gas-X and Pepto-Bismul with no relief. He denies having fever, nausea or vomiting. He denies eating out at any restaurants recently. No sick contacts for recent travel. No recent contact with reptiles or petting zoos. No dysuria or hematuria.

On physical examination the patient's abdomen is soft, moderately distended and diffusely tender to palpitation with decreased bowel sounds. 

An acute abdominal series and CT scan of the abdomen/pelvis are obtained. 

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The actual diagnosis for this real-life case will be posted in 1 week.  

Diagnosis: Superficial Venous Thrombosis

A duplex ultrasound study was obtained of the left upper extremity which revealed a superficial brachial vein thrombosis without evidence of a deep venous thrombosis. Vascular surgery was consulted and recommended no surgical intervention. The patient was instructed to apply warm compresses to his proximal forearm and to take ibuprofen as needed for pain.

Unlike a deep venous thrombosis (DVT), a superficial venous thrombosis does not require anticoagulative therapy. Patients can develop superficial venous thrombi in the upper extremities as a complication of having an arteriovenous fistula, however thrombi in the superficial venous system generally do not cause clinically significant thromboembolic disease and tend to self-resolve.

It is important to check the patient's arteriovenous fistula for a palpable and/or audible thrill to ensure it is functioning properly. Warm compresses can be applied to aid clot dissolution and NSAIDs taken for symptomatic pain.

References: 

Rosen's Emergency Medicine Concepts and Clinic Practice, 8th Ed, 2014, Chapter 88: Pulmonary Embolism and Deep Venous Thrombosis by Jeffrey A. Kline

Edematous Digits

A 45 year-old male with history of end-stage renal disease secondary to type 2 diabetes on hemodialysis presents with chief complaint of left hand pain and wrist swelling for the past 8 days. 

The patient says his symptoms came on gradually and have been more or less persistent since onset. Pain is 3/10 and described as a dull ache. No history of trauma. He decided to come into the emergency department today because the pain and swelling do not appear to be getting any better and he is concerned. The patient says he was last dialyzed yesterday. 

He denies having any recent fever, chills, nausea, vomiting, diarrhea, abdominal pain, chest pain, or shortness of breath. 

On exam you note the presence of an arteriovenous fistula in the proximal left forearm with palpable and audible thrill to auscultation. Radial pulses are 3+ bilaterally with equal sensation and strength in both hands as well as full range of motion in both wrists and all digits. All joints in the left upper extremity are non-tender.

Can you guess the diagnosis?

Leave a comment below and tell us how you would manage this patient. 

The actual diagnosis for this real-life case will be posted in 1 week.