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      Frail Patient with Abdominal Pain

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          Abstract

          Volvulus is a frequent condition in patients presenting in the emergency department (ED) with abdominal pain. While cecal volvulus occurs more often in young patients, sigmoid volvulus is more common in elderly patients.

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          CT findings of sigmoid volvulus.

          Jeffrey M Levsky, R A Dubrow, Anneke den Hollander … (2009)
          The purpose of this study was to evaluate the features of sigmoid volvulus on CT scanograms and cross-sectional images. We retrospectively reviewed 21 cases of sigmoid volvulus in 15 men and six women. Three radiologists evaluated scanograms and cross-sectional images for several classic and two novel imaging signs of volvulus: crossing sigmoid transitions (called the X-marks-the-spot sign) and folding of the sigmoid wall by partial twisting (called the split-wall sign). A general impression was assigned to scanograms and cross-sectional images. CT findings suggesting bowel compromise were compared with pathologic and endoscopic findings. The most sensitive scanogram findings were absence of rectal gas (19 of 21 cases, 90%) and an inverted-U-shaped distended sigmoid (18 of 21 cases, 86%) followed by the coffee bean sign and disproportionate sigmoid enlargement (both 16 of 21 cases, 76%). The most sensitive cross-sectional findings were one sigmoid colon transition point (20 of 21 cases, 95%) and disproportionate enlargement of the sigmoid (18 of 21 cases, 86%). The X-marks-the-spot and split-wall signs were present in nine of 21 (43%) and 11 of 21 (52%) patients, but one of the two signs was present in 18 of 21 patients (86%). Classic radiographic and definitive cross-sectional findings were seen in 11 of 21 (52%) and 16 of 21 (76%) patients. CT findings were definitive in five of seven patients (71%) with indeterminate scanogram findings. Imaging signs suggesting bowel compromise correlated poorly with clinical ischemia, but CT features were present in all three patients with frank necrosis. Sigmoid volvulus has a spectrum of imaging findings. A classic appearance is absent on approximately one half of scanograms and one fourth of CT scans. Use of new signs that model the pathophysiologic characteristics of volvulus (X-marks-the-spot sign for more complete twisting and split-wall sign for less severe twisting) may improve diagnostic confidence.
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            Sigmoid volvulus: diagnostic twists and turns.

            Ling Tiah, S. Y. Matthew Goh (2006)
            The purpose of this study was to describe the clinical profile of patients with sigmoid volvulus and highlight the diagnostic difficulties and pitfalls. This was a retrospective descriptive study of patients with sigmoid volvulus seen at a community hospital over a 5-year period from July 1999 to July 2004. Twenty-eight cases of sigmoid volvulus were identified, of which 16 were male and 12 female. The median age was 74 years. Twenty-seven were Chinese and one was Malay. Seven out of 28 patients were from nursing institutes while the rest came from their own homes. Eleven were bedridden and chronic constipation was a problem for 17 patients. Co-existing medical illnesses, including neuropsychiatric conditions, were common. Abdominal distension and pain were the most frequent presentations (26 and 21 patients, respectively). Twelve patients had constipation and 11 had diarrhoea. Only nine had the complete typical triad of abdominal distension, pain and constipation. The classical coffee-bean sign was identified in nine out of 26 initial plain abdominal radiographs done at the emergency department and a further 11 were diagnosed after review by the surgical team in the ward. Another four were identified only after computed tomography scan of the abdomen and pelvis. The remaining two patients were diagnosed intra-operatively after they underwent emergency laparotomy. As our aged population continues to grow, sigmoid volvulus may be more commonly encountered. Emergency physicians should maintain a high index of suspicion and avoid the pitfalls so as to prevent delay in diagnosis and treatment.
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              83-year-old woman with abdominal distention and constipation.

              Y. Takahashi, Mohammad Albaba (2009)
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                Author and article information

                Journal
                Journal ID (nlm-ta): West J Emerg Med
                Journal ID (publisher-id): WestJEM
                Title: Western Journal of Emergency Medicine
                Publisher: Department of Emergency Medicine, University of California, Irvine School of Medicine
                ISSN (Print): 1936-900X
                ISSN (Electronic): 1936-9018
                Publication date (Print): September 2010
                Volume: 11
                Issue: 4
                Pages: 400-401
                Affiliations
                [* ]High Dependency Unit, San Giovanni Bosco Hospital, Torino, Italy
                [† ]Radiology, San Giovanni Bosco Hospital, Torino, Italy
                Author notes
                Address for Correspondence: Fabrizio Elia, MD, Medicina d’Urgenza, Ospedale San Giovanni Bosco, Piazza Donatore del Sangue 3, 10154 Torino Italy. Email: fabrizioelia@ 123456yahoo.it

                Supervising Section Editor: Rick A. McPheeters, DO

                Article
                Publisher ID: wjem11_4p400
                PMC ID: 2967700
                PubMed ID: 21079720
                SO-VID: d0ab8760-36f9-49d0-8844-7351183f9e1a
                Copyright © Copyright © 2010 the authors.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.

                History
                Date received : 25 March 2010
                Date revision received : 28 April 2010
                Date accepted : 6 May 2010
                Categories
                Subject: Cardiology
                Subject: Images In Emergency Medicine

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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