Sigmoid Volvulus

Question 1

85-year-old lady living in care home. She uses a wheelchair and had a long-standing constipation. She presented in the A&E with abdominal pain, constipation, marked abdominal distention, vomting and dehydration.
Labs: Na 120, ABG: PH 7.5, PCO2 4.2

Q1: What are the possible causes of this clinical picture?

Answer 1

Sigmoid volvolus due to age and chronic constipation

Question 2

Q2: What is your interpretation of this ABG?

Answer 2

Met alk.

Question 3

Q3: How would manage this patient?

Answer 3

CCRISP protocol
NPO – Ng tube – Fluid resus – foley cath – Bloods (FBC – CRP – ESR – U&E – LDH – Cr. ) – Fluid NS – Monitor vitals
Then – early de flex. Sigmoidoscopy
any signs ischemia of perforation – surgery

Question 4

Q4: Explain the biochemical abnormalities:
Alkalosis
Hyponatremia
Hypokalemia
Hypochloremia Loss of Cl in vomitus
Raised bicarbonate
Aciduria

Answer 4

Alkalosis Loss of H ion
Hyponatremia loss of Na in vomitus and initially NAHCO3 excreation to reduce alkalosis
Hypokalemia Loss of K in vomitus and increase aldosterone in respose to hypovolumeia lead to K excreation and Na absorption
Hypochloremia Loss of Cl in vomitus
Raised bicarbonate Loss of HCL body will try to compensate by another acid NAHCO3,
Decrease acidic load in duodenum – > retenton of bicarb
Aciduria paradoxical due to loss of H ion in urine

Question 5

Q5: What are the symptoms and sings of sigmoid volvolus?

Answer 5

Obstipation early sign / Constipation / Abd pain and destention / Vomiting / signs of dehydration and sepsis and oligura
Absent intsidtinal sound

Question 6

Q6: What are its complications?

Answer 6

Bowel ischemia / Mesentric detorsion / gangrene / Perforation / fecal peritonitis / Sepsis

Question 7

Q7: Who are you going involve in the care of this lady ?

Answer 7

Colorectal surgeon / Anesthesia / Level 2 Facility nurse.
Why lvl 2; Line placement, ECG monitoring and fluid electrolyte therapy

Question 8

Q8: What are the different surgical options for treating a patient with sigmoid volvolus?

Answer 8

Laparotomy show status of sigmoid
If No signs of ischemia – > resotre normal position of sigmoid.
If ischemic – > Hartman / 2nd opt resection and anastomosis

Question 9

Q9: What are the clinical manifestatiions of hyponatremia?

Answer 9

Confusion due to cerebral edema / Agitation / Seizures / cardiac arrythemia

Question 10

Q10: What are the causes of hyponatremia?

Answer 10

According to osmolarity could be
(Isotonic – Hypotonic (Hypo / Hyper/Euvolemic)- Hypertonic )
Depletion (Hypovolemic); Diarrhea, Diretics, Burns
Dilutional (Hypervolemic); HF , Over admin Glu 5%
Endocrine(Euvolemic) ; Addison dis / hypothyroidism
Pseudohypo; MM

Question 11

Def of volulus

Answer 11

Twisting or around its mesentery
If torsion more than 360 ischemia