A 42-year-old woman with a 9-year history of scleroderma presents with diffuse abdominal pain, distension, colon dilation, and leukocytosis. What is the next step?

• A. Laparotomy
• B. Colonoscopic decompression
• C. Intravenous antibiotics only
• D. Nasogastric decompression with observation

Answer: (A)

Acute colonic dilatation with systemic toxicity in a patient with scleroderma. When the colon becomes massively distended in this setting, the situation can rapidly progress to colonic ischemia or perforation. The presence of diffuse pain with leukocytosis signals systemic involvement and possible evolving necrosis, so waiting to try nonoperative measures risks catastrophe.

Surgical exploration is needed to decompress the bowel, assess viability, and resect nonviable segments if present. Laparotomy allows direct decompression and definitive management, which is why it’s the appropriate next step here.

Nonoperative approaches like nasogastric decompression or colonoscopic decompression are reserved for stable patients without signs of peritonitis or necrosis; IV antibiotics alone do not address the dangerous distention. Intravenous antibiotics are supportive but not definitive when there are signs pointing toward impending perforation or ischemia.