What is the treatment for an elderly patient with abdominal colic, distention, absolute constipation, vomiting, pallor, and a palpable lower abdominal mass?

Treatment for Elderly Patient with Bowel Obstruction

Hartmann's procedure (option D) is the most appropriate treatment for an elderly patient presenting with abdominal colic, distention, absolute constipation, vomiting, pallor, and a palpable lower abdominal mass.

Clinical Assessment and Diagnosis

The clinical presentation strongly suggests a large bowel obstruction, specifically sigmoid volvulus or obstructing sigmoid colon cancer:

• Abdominal colic, distention, and absolute constipation are classic signs of mechanical bowel obstruction 1
• Vomiting indicates established obstruction 2
• Pallor suggests possible blood loss or systemic compromise
• Palpable lower abdominal mass is highly concerning for a dilated sigmoid colon (volvulus) or tumor mass 1
• Advanced age increases risk of complications and mortality 1

Rationale for Hartmann's Procedure

1. Emergency situation requiring definitive treatment: The combination of absolute constipation, vomiting, and pallor indicates a complete obstruction with potential for ischemia or perforation 1, 2

2. Safety profile in elderly patients: Hartmann's procedure provides definitive treatment while avoiding the risks of primary anastomosis in an unprepared, potentially ischemic bowel 1

3. Guidelines support: The World Journal of Emergency Surgery guidelines recommend Hartmann's procedure for emergency cases of sigmoid volvulus or obstructing colorectal cancer when the patient is not suitable for primary anastomosis 1

4. Mortality risk reduction: In elderly patients with bowel obstruction, Hartmann's procedure has lower mortality compared to primary anastomosis in emergency settings 1

Why Other Options Are Less Appropriate

• Sigmoidectomy with primary anastomosis: Too risky in an unprepared bowel with potential ischemia in an elderly patient 1

• Ilioanal pouch: This complex reconstructive procedure is inappropriate for emergency situations and typically used for inflammatory bowel disease or familial adenomatous polyposis 1

• Right hemicolectomy: Not anatomically appropriate for a lower abdominal pathology; right hemicolectomy is indicated for right-sided colon lesions 1

Management Algorithm

1. Initial stabilization:

   • IV fluid resuscitation
   • Nasogastric tube decompression
   • Broad-spectrum antibiotics 1, 2

2. Preoperative assessment:

   • CT scan with IV contrast to confirm diagnosis and assess for complications 2
   • Correction of electrolyte abnormalities
   • Optimization of comorbidities if time permits

3. Surgical approach:

   • Hartmann's procedure: resection of affected sigmoid colon with end colostomy and rectal stump closure 1
   • Consider damage control approach if patient is hemodynamically unstable 2

4. Postoperative care:

   • Close monitoring for complications
   • Early mobilization
   • Consideration for stoma reversal after 3-6 months in suitable candidates 1

Important Considerations

• Mortality risk is significantly higher in elderly patients (>60 years) and those presenting with shock 1
• Careful attention to fluid and electrolyte management is essential 2
• Early surgical consultation and intervention is critical when signs of complete obstruction are present 2
• Nutritional support should be initiated early if oral intake will be delayed 2

Hartmann's procedure provides the safest definitive treatment while minimizing the risk of anastomotic leak in this high-risk scenario of an elderly patient with signs of complete large bowel obstruction.