From the Guidelines
The definitive management for an 82-year-old woman with dementia presenting with abdominal pain, distension, and radiographic evidence of a significant volvulus is emergent laparotomy. While sigmoidoscopy can be attempted initially for sigmoid volvulus decompression, the patient's advanced age, presence of dementia, and significant volvulus on imaging suggest a high risk of bowel ischemia, perforation, or recurrence 1. Emergent laparotomy allows direct visualization of the bowel, assessment of viability, detorsion of the volvulus, and resection of any nonviable segments. Barium enema is contraindicated in suspected volvulus as it may worsen the obstruction or lead to perforation 1. Nasogastric decompression is only a temporary supportive measure that doesn't address the underlying mechanical obstruction. Given the patient's age and comorbidities, prompt surgical intervention is necessary to prevent complications like bowel necrosis, perforation, and sepsis, which carry high mortality rates in elderly patients 1.
Some key points to consider in the management of sigmoid volvulus include:
- The high risk of recurrence after endoscopic decompression, which can be as high as 43-75% 1
- The importance of prompt surgical intervention in preventing complications and improving outcomes 1
- The need for a multidisciplinary approach, taking into account the patient's overall clinical condition and comorbidities 1
- The role of laparoscopic surgery in the management of sigmoid volvulus, which may be suitable for select cases but requires further study 1
Overall, the management of sigmoid volvulus requires a careful and individualized approach, taking into account the patient's specific clinical presentation and risk factors. Emergent laparotomy is the most appropriate definitive management for this patient, given the high risk of complications and the need for prompt surgical intervention 1.
From the Research
Definitive Management of Volvulus
The definitive management of volvulus, particularly in the case of an 82-year-old woman with dementia presenting with abdominal pain and a significant volvulus on abdominal radiograph, involves surgical intervention. The key considerations include:
- The type of volvulus (e.g., gastric, sigmoid) and its complications
- The patient's overall health status and ability to tolerate surgery
- The potential benefits and risks of different surgical approaches (e.g., laparoscopic vs. open)
Surgical Options
The following surgical options are considered for the management of volvulus:
- Emergent laparotomy: This is a surgical procedure where the abdomen is opened to diagnose and treat the volvulus. It is often necessary in emergency situations where there is a risk of bowel ischemia or perforation 2, 3.
- Laparoscopic repair: This is a minimally invasive surgical approach that involves using a laparoscope to visualize the volvulus and perform the necessary repairs. It has been shown to be effective in the management of gastric volvulus, with improved postoperative outcomes and quality of life compared to open surgery 4, 5.
- Endoscopic decompression: This is a procedure where a flexible tube with a camera (endoscope) is used to visualize the volvulus and relieve any obstruction. It is often used in the management of sigmoid volvulus, with a high success rate and low complication rate 6.
Conclusion Not Allowed, Hence Removed and Replaced with
Key Considerations
In the case of an 82-year-old woman with dementia presenting with abdominal pain and a significant volvulus, the definitive management would likely involve emergent laparotomy or laparoscopic repair, depending on the specific type of volvulus and the patient's overall health status. The decision to proceed with surgery should be made on a case-by-case basis, taking into account the potential benefits and risks of each approach, as well as the patient's individual needs and circumstances 4, 6, 5, 2, 3.