From the Guidelines
The next step for this patient with abdominal pain, stable vital signs, and imaging showing sigmoid thickening with thumbprint sign due to edema would be option D: CTA (Computed Tomography Angiography). This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of prompt CTA in suspected acute mesenteric ischemia (AMI) [ 1 ]. The findings of sigmoid thickening and thumbprint sign due to edema are suggestive of ischemic colitis, which requires urgent vascular assessment to evaluate mesenteric blood flow, identify potential vascular occlusions or stenosis, and determine the extent of bowel compromise.
Key Considerations
- CTA is the diagnostic study of choice for suspected AMI, as it provides detailed information about vascular supply and bowel compromise without being invasive [ 1 ].
- Delay in diagnosis is a major factor contributing to high mortality rates in AMI, and every 6 hours of delay in diagnosis doubles mortality [ 1 ].
- Comprehensive biphasic CTA includes pre-contrast scans, arterial and venous phases, and multi-planar reconstructions to assess the origin of the mesenteric arteries [ 1 ].
- CTA should be performed despite the presence of acute kidney injury, as the consequences of delayed or missed diagnosis are far more detrimental for patients than exposure to the iodinated contrast agent [ 1 ].
Comparison of Options
- Colonoscopy (option A) may eventually be needed for direct visualization but carries a perforation risk in potentially ischemic bowel and should be deferred until vascular status is clarified.
- Diagnostic laparoscopy (option B) and exploratory laparotomy (option C) are premature without first determining if the condition can be managed medically or requires surgical intervention based on vascular findings.
- Sigmoidoscopy (option E) is not the immediate next step, as CTA provides more comprehensive information about vascular supply and bowel compromise.
Conclusion Not Applicable
Instead, the focus is on the immediate next step in management, which is CTA (Computed Tomography Angiography), as supported by the latest guidelines and evidence [ 1 ].
From the Research
Next Steps for Patient with Abdominal Pain
The patient presented with abdominal pain, is vitally stable, and imaging showed increased thickness of sigmoid and thumbprint sign due to edema. Considering the patient's stability, the next step should focus on further diagnostic evaluation to determine the cause of the abdominal pain and edema.
Diagnostic Options
- CTA (Computed Tomography Angiography): Given the patient's stable condition, a CTA could be a suitable next step to evaluate the vascular system and potential causes of the edema, such as ischemia or vascular occlusion 2, 3, 4.
- Other Options: While other diagnostic procedures like colonoscopy, diagnostic laparoscopy, exploratory laparotomy, and sigmoidoscopy are available, they may not be the immediate next step without further evaluation of the patient's condition.
Rationale
The use of CTA is supported by studies that highlight its effectiveness in diagnosing vascular diseases and evaluating patients with abdominal pain 2, 3, 4. Additionally, CTA has been shown to be a valuable tool in assessing coronary artery disease and can provide a comprehensive evaluation of the vascular system 5, 4.
Considerations
It is essential to consider the patient's overall condition, medical history, and the results of the initial imaging studies when determining the next steps in management. The choice of diagnostic procedure should be guided by the patient's specific needs and the potential benefits and risks associated with each option.