The Frail Patient with an Obstructing Sigmoid Tumour
An 84-year-old woman presents with 5 days of absolute constipation, vomiting and progressive abdominal distension. She lives alone with carers twice daily and has mild cognitive impairment. Comorbidities: heart failure with ejection fraction 35%, stage 3 chronic kidney disease (eGFR 38), and two previous myocardial infarctions. Observations: HR 104, BP 108/64, RR 24, SpO2 94% on air, temperature 37.4 C. Abdomen is grossly distended and tympanic with generalised tenderness but no rigidity. CT shows a large bowel obstruction at the sigmoid due to a 5 cm tumour, with a caecum of 11 cm and no free gas. WCC 13.8, CRP 45, creatinine 190 micromol/L (baseline 140), lactate 2.8. The anaesthetic registrar documents her as ASA 4 and suggests 'best supportive care only'.
1. Assess the severity of this presentation and outline your initial management, distinguishing what is urgent from what can wait.
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This is a large bowel obstruction with a closed-loop risk, a caecum of 11 cm approaching the perforation threshold (often quoted around 9-12 cm), and early sepsis with a lactate of 2.8 and acute kidney injury. She is not a candidate for purely supportive care without a proper senior assessment.
Urgent (next hours):
- Resuscitate with careful fluid balance: she has heart failure and CKD, so give measured crystalloid boluses (250-500 mL) with close monitoring of urine output, JVP and chest, rather than large-volume resuscitation. Catheterise.
- Nasogastric tube for decompression and symptom control; antiemetics.
- Broad-spectrum antibiotics after cultures, given sepsis and possible translocation.
- Correct electrolytes, particularly potassium, before any intervention.
- Urgent senior surgical and anaesthetic review; the ASA 4 label should be challenged and a formal risk assessment made.
- Consider an urgent colorectal MDT discussion.
Can wait briefly: definitive oncological staging and any discussion of curative resection. The immediate issue is decompression and sepsis control.
Decompression options:
- Endoscopic stenting of the sigmoid is attractive: it relieves obstruction, allows resuscitation and optimisation, and can act as a bridge to elective surgery or as palliation. Risk of perforation is around 5%.
- A defunctioning stoma is an alternative if stenting fails or is unavailable.
- Surgery (Hartmann's procedure) carries high mortality in this frail patient with cardiac disease and should be reserved for perforation, failed stenting or deterioration.
Aim for a shared decision with the patient and family, but do not default to supportive care before decompression has been attempted.
2. The patient improves after successful stenting and is now being considered for elective surgery. How would you structure the decision about definitive treatment, and what would you recommend?
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Structure the decision around four domains:
- Prognosis and goals. What does she understand and want? With cognitive impairment, involve her carers and any lasting power of attorney, and establish her pre-morbid function and values.
- Fitness for surgery. Use a validated tool such as the ACS NSQIP risk calculator or P-POSSUM, and a cardiopulmonary exercise test or cardiology review if time permits. Her ejection fraction of 35%, CKD and prior infarcts make major resection high risk, but the risk is not prohibitive if optimised.
- Oncological benefit. Staging with CT chest and liver is needed. If there is metastatic disease, resection offers little survival benefit and stenting plus chemotherapy or palliation is preferred.
- Alternatives. Stent alone with surveillance, or a defunctioning stoma, versus resection.
Recommendation: If staging shows localised disease and she wishes to pursue curative intent, proceed with an elective anterior resection after optimisation: correct anaemia and electrolytes, review cardiac medications with cardiology, involve a geriatrician for delirium prevention, and use an enhanced recovery pathway. If metastatic or if she prioritises comfort, leave the stent in place with a plan for re-intervention if it occludes, and refer to palliative care.
The key judgement is that a stent is a bridge, not automatically a destination, and that the decision must be individualised rather than driven by the ASA score alone.