Ileosigmoid knotting: An unusual cause of intestinal obstruction

Ileosigmoid knotting: An unusual cause of intestinal obstruction ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Ileosigmoid knotting: An unusual cause of intestinal obstruction Mahim Koshariya*, Arpan Choudhary, Narendra Gome, Arvind Meravi, A. Rai, M. C. Songra Department of Surgery, Gandhi Medical College, Bhopal, Madhya Pradesh, India *Corresponding author email: [email protected] to cite this article: Mahim Koshariya, Arpan Choudhary, Narendra Gome, Arvind Meravi, A. Rai,M. C. Songra. Ileosigmoid knotting: An unusual cause of intestinal obstruction. IAIM, 2015; 2(4): 179-181. Available online at www.iaimjournal.comReceived on: 18-03-2015 Accepted on: 30-03-2015AbstractIleosigmoid knot or double volvulus is an unusual cause of intestinal obstruction and presents as asurgical emergency. It affects men of middle and old age. It occurs due to entangling of ileal andsigmoid loops producing obstruction and strangulation. Here, we have described a case of 60 yearsold male presented with features of intestinal obstruction. Emergency laparotomy revealedileosigmoid knotting with gangrene of involved segment. Resection of unviable portion with knotwas done with double primary anastomosis and covering ileostomy.Key wordsIleosigmoid knot, Double volvulus, Intestinal obstruction, Gangrene.Introduction occurs mostly in males in between their 4th and 6th decade of life. However it has also beenIleosigmoid knotting, also known as compound reported in children [2].volvulus or double volvulus is a condition wherethe ileum wraps around the sigmoid colon and Case reportits mesentery. It is a rare surgical emergency,difficult to diagnose preoperatively. This is a A 60 years old male patient presented withsurgical emergency that requires urgent complaints of severe pain in abdomen,exploration and resection of gangrenous bowel distension of abdomen and not passing flatusand untwisting of the volvulus. Ileosigmoid knot and motion since 1 day. In past, patient hador double volvulus is an uncommon event where intermittent bouts of pain in abdomen for 2loops of ileum get wrapped around the years and constipation for 1 year. There was noredundant sigmoid colon causing obstruction of history of bleeding per rectum and melena. Onboth, and rapidly progressing to gangrene [1]. It admission patient was dehydrated, with pulseInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 179Copy right © 2015, IAIM, All Rights Reserved.

Ileosigmoid knotting: An unusual cause of intestinal obstruction ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)140/min and blood pressure 90/60 mmHg. Per of life [4]. Predisposing factors described areabdominal examination revealed distended high fiber diet, frail and debilitated patient,abdomen and tenderness, all over the abdomen. chronic laxative use, hyper mobile smallGuarding, rigidity and shifting dullness were also intestine with markedly elongated mesentery.presented suggestive of peritonitis. Bowel Primary event is usually a hyperactive ileumsounds were absent. Digital rectal examination winding around the narrow pedicle of a passiveshowed empty rectum, tenderness and sigmoid.bogginess over anterior rectal wall, otherfindings were normal. Erect X-ray abdomen Photo - 1: Intra-operative dilated gangrenousshowed dilated small and large bowel loops. sigmoid colon.Routine blood investigations were within normallimit, except increase in total leukocyte count. Inview of diagnosis of acute intestinal obstruction,exploratory laparotomy was planned.Intra-operatively twisting of distal ileum and Photo - 2: Gangrenous sigmoid colon andsigmoid colon was noted causing gangrene of terminal ileum with normal primal bowel loops.involved segments, i.e. of sigmoid colon (Photo -1) and ileum (Photo - 2) along with 2.5 liters ofserosanguinous fluid. Resection of gangrenousbowel was done along with the knot, withoutany attempt to untwist it. Intestinal continuityrestored with colo-rectal and ileo-transverseanastomosis, with covering loop ileostomy.Postoperatively patient recovered quickly, withstable vitals and soft abdomen. Ileostomystarted functioning from 2nd day onward.Successful stoma closure was done after 8weeks.DiscussionIleosigmoid knotting also known as double Preoperative diagnosis is seldom obtained.volvulus, compound volvulus, and intestinal Findings of plain X- ray abdomen include aknotting, occurs as a loop of small intestine dilated loop of the pelvic colon, the evidence ofdescends into left paracolic gutter to encircle a small intestinal obstruction, retention of fecesthe sigmoid in clockwise or an anti clockwise in an undistended proximal colon anddirection. As the knot tightens the bowel encroachment of small bowel loops in left iliacobstructs forming a double closed loops and the fossa. CT abdomen shows dilated loop ofmesenteric involvement usually progresses to intestine with central mesenteric vesselsearly strangulation [1]. The long pelvic forming characteristic whirl and tightly twistedmesocolon allows the ileum to twist around the ileum [5].sigmoid colon and then become gangrenous [3].It occurs mostly in men in their 4th to 6th decadeInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 180Copy right © 2015, IAIM, All Rights Reserved.

Ileosigmoid knotting: An unusual cause of intestinal obstruction ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Treatment includes resuscitation followed by Referencessurgery. Surgical options depend upon the 1. Shepherd JJ. Ninety-two cases ofcondition of bowel, with viable intestinal loops, ileosigmoid knotting in Uganda. Br. J ofuntying of knot is sufficient, however most cases surgery, 1967; 54: 561-566.presents with gangrene demanding en blockresection of knot and double primary 2. Ghassan A. Al-Nasir, M. M. Mohammed.anastomosis of ileal and sigmoid segments [1, Ileosigmoid knot Review of Literatures6]. Other options available are closure of distal and Record of Seven Cases. IJGE, 2002;ileal stump with end to side ileo-colic bypass 1(3).anastomosis, however it can produce blind loopsyndrome. Old age, delay in diagnosis and 3. Kakar A., Bhatnagar B.N.S. Ileosigmoidextensive gangrene impart poor prognosis [7]. Knotting: A clinical study in 11 cases. Australia and New Zealand Journal of Surgery, 1981; 51: 456.Conclusion 4. Scott Q. J. Ileosigmoid knot and sigmoid volvulus. S Afr J Surg, 1973; 11: 29-32.Ileosigmoid knotting also known as double 5. Lee S.H, Park Y.H, Won Y.S. Thevolvulus, compound volvulus, and intestinal ileosigmoid knot: CT findings. AJR Am Jknotting is an uncommon cause of intestinal Roentgenol, 2000; 174: 685-687.obstruction. Preoperative diagnosis is difficult 6. Akgun Y. Management of ileosigmoidand it rapidly progress to gangrene. It should be knotting. Br J Surg, 1997; 84: 672-673.considered as a differential diagnosis in a elderly 7. Puthu D, Rajan N, Shenoy G.M, Pai SU.male presenting with features of acute intestinal The ileosigmoid knot. Dis Colon Rectum,obstruction. Prompt surgery with resection of 1991; 34: 161-166.gangrenous segment and anastomosis is thetreatment of choice.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 181Copy right © 2015, IAIM, All Rights Reserved.