A 65-Year-Old Man With a Hugely Distended Abdomen

Prashanth Rawla, MD; Jeffrey Pradeep Raj, MD


October 24, 2019

The patient in this case was initially treated with conservative measures, including giving him nothing by mouth, intravenous fluid hydration, and placement of a nasogastric tube. He was given neostigmine with initial improvement in his condition; however, his abdominal distention worsened the next day. He underwent colonoscopy with decompression twice during this admission, and his symptoms markedly improved. Colonoscopy showed no signs of mechanical obstruction (Figure 5).

Figure 5.

In patients with ACPO, surgical intervention is the last resort after conservative management if colonic decompression fails or if clinical signs of perforation, ischemia, or abdominal sepsis are present.[10,30] Tube cecostomy is the procedure of choice if ischemic perforation is not present; the tube may be removed later without another surgical intervention.[16,31] However, a cecal or right colon resection is needed if the cecal wall is thin due to severe dilatation.[10,31]

On the other hand, if signs suggest perforation or bowel ischemia, an emergency laparotomy should be performed. The affected segment should be resected, followed by primary anastomosis or a diversion procedure, depending on the presence of perforation, fecal contamination, and the extensiveness of the bowel segment affected.[10,32] Total abdominal colectomy may be the preferred intervention in patients with chronic constipation, colonic pseudo-obstruction, and a transitional zone in the left colon, whereas a subtotal colectomy is recommended in some patients with perforation.[33] If surgery is indicated, precautions include perioperative fluid management sufficient enough to ensure intestinal perfusion and prophylactic intravenous antibiotics.[32,33]

Case Challenge Quiz Questions

A 73-year-old woman with mild Alzheimer disease presents to the emergency department with abdominal distention. She has had constipation for 5 days and progressive abdominal distention for the past 3 days. She also describes anorexia and nausea without vomiting.

Upon examination, the patient appears to be in mild distress with abdominal distention. Her vital signs are all within the normal limits. Examination of the abdomen reveals a markedly distended abdomen with diminished bowel sounds and moderate discomfort on palpation of the left side without rebound tenderness or guarding. Her laboratory findings are as follows:

  • Sodium level: 137 mmol/L

  • Potassium level: 2.5 mmol/L

  • Chloride level: 108 mmol/L

  • BUN level: 41 g/dL

  • Creatinine level: 1.10 mg/dL

  • Glucose level: 107 mg/dL

CT scanning of the abdomen reveals significant cecal dilatation as large as 11 cm in diameter with no signs of peritonitis or obstruction.


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