Management of Dilated Sigmoid Colon in a 4-Month-Old Infant
A 4-month-old infant with a dilated sigmoid colon requires urgent surgical evaluation to rule out congenital segmental dilatation (CSD) or underlying motility disorders, as this presentation in neonates and young infants is extremely rare and typically necessitates surgical resection rather than conservative management.
Initial Diagnostic Workup
Imaging Assessment
- Plain abdominal radiographs should be obtained immediately to assess the extent of colonic dilatation and rule out acute volvulus (look for "coffee bean sign" if volvulus is present) 1, 2
- Abdominal CT with contrast is the gold standard if diagnosis remains unclear or if complications such as ischemia or perforation are suspected, revealing dilated colon with air/fluid levels and potentially the "whirl sign" if volvulus is present 1, 2
- In this age group, the imaging will help differentiate between congenital segmental dilatation versus acute volvulus 3, 4
Critical Clinical Distinctions
This is NOT typical sigmoid volvulus: The provided guidelines focus on adult sigmoid volvulus (mean age 56-77 years), which is exceedingly rare in infants 2, 5. At 4 months of age, you are dealing with either:
- Congenital Segmental Dilatation (CSD) - Only 10 neonatal cases reported in literature, presenting with gross abdominal distension from birth 3
- Pediatric sigmoid volvulus with underlying anatomic abnormality - Extremely rare, median age 7 years in pediatric cases 6, 7
Immediate Management Algorithm
If Signs of Obstruction, Ischemia, or Perforation Present:
- Proceed directly to emergency laparotomy - do not attempt endoscopic decompression in infants 1, 5
- Surgical options include:
If Stable Without Peritonitis:
- Urgent pediatric surgical consultation is mandatory regardless of stability 3, 7
- Do NOT attempt endoscopic detorsion in a 4-month-old - this is only appropriate for older children/adolescents and adults 6
- Prepare for surgical intervention as definitive treatment
Surgical Approach
Operative Findings Will Guide Resection:
- For CSD: Resect the dilated segment with histologic confirmation (expect normal ganglion cells but abnormal architecture) 3, 4
- For volvulus with redundant colon: Resect redundant sigmoid to prevent recurrence 6, 7
- If hypoganglionosis found: May require more extensive resection depending on distribution 7, 4
Histologic Evaluation is Essential:
- Send specimens for full-thickness biopsy to assess ganglion cell distribution 3, 7, 4
- CSD shows normal ganglion cells but may have hypertrophied muscularis propria and abnormal nerve plexus location 4
- Hypoganglionosis has been reported in pediatric sigmoid volvulus cases and requires different surgical planning 7
Critical Pitfalls to Avoid
Do not apply adult sigmoid volvulus guidelines to infants: The 2023 World Journal of Emergency Surgery guidelines specifically address adult patients and pregnant women, but provide no guidance for neonates or young infants 1. Endoscopic detorsion, which is first-line in adults, is not appropriate for this age group 1, 2, 5.
Do not delay surgical consultation: Unlike adults where conservative management may be attempted, pediatric cases (especially neonates) frequently present as fulminant obstruction requiring prompt surgical decision-making 7, 8.
Assess for associated anomalies: The reported neonatal CSD case had trisomy 21 and ventricular septal defect, requiring cardiac correction before definitive anastomosis 3. Screen for other congenital abnormalities.
Postoperative Considerations
- Staged reconstruction may be necessary: Initial Hartmann procedure with delayed anastomosis (at 5 months in the reported case) after addressing comorbidities 3
- Long-term follow-up required: Monitor for bowel function and potential need for additional interventions 3, 7
- Recurrence prevention: Complete resection of abnormal bowel segment is essential, as inadequate resection leads to recurrence 6, 7