Ileosigmoid knotting: A rare cause of acute abdomen with fatal outcome in a 60-year-old man: Case report from a resource-limited setting

Abstract

Introduction and importance: Ileosigmoid knotting(ISK), a rare but life-threatening condition which first described in 1845. It occurred when the ileum twisting around the sigmoid colon and causing intestinal obstruction and potential perforation.

Presentation of case: A 60-year-old male from the Garbo region of Somali, Ethiopia, presented to the hospital after a a four-day history of intestinal obstruction symptoms. On examination, he was tachycardic and febrile, and exhibited diffuse abdominal tenderness. A diagnosis of intestinal obstruction with generalized peritonitis was made after abdominal x ray. The patient was resuscitated with fluids, started on antibiotics, and a nasogastric tube was placed. Emergency laparotomy revealed ileosigmoid knotting with gangrenous bowel. En bloc resection of the affected ileum and sigmoid colon was performed. An ileo-jejunal anastomosis and an end colostomy were constructed. Despite these interventions, the patient succumbed to uncontrolled sepsis on the fourth postoperative day.

Clinical discussion: Ileosigmoid knotting (ISK), a rare and deadly form of intestinal obstruction, is more common in the "volvulus belt" regions like Africa and parts of Asia. It involves a twisted knot of the ileum and sigmoid colon and can be caused by factors like a narrow mesentery or hypermobile ileum. ISK is difficult to diagnose with standard tests and often requires surgical exploration. The mortality is high (up to 48 %), especially in resource-limited settings due to various challenges.

Conclusion: Ileosigmoid knotting is a rare and dangerous cause of intestinal obstruction requiring quick action. Poor outcomes are common, especially in resource-limited areas like Ethiopia due to late presentation and limited healthcare resources.

Keywords: Case report; Ethiopia; Ileosigmoid knotting; Intestinal obstruction; Resource limiting setup.

Fig. 1

Abdominal X-ray demonstrated marked distention of a large bowel loop extends from the right lower quadrant to the left upper quadrant. Multiple dilated, centrally located small bowel loops with valvulae conniventes spanning their diameter are also noted, consistent with upstream small bowel dilation. No free intraperitoneal air or air-fluid levels are present.

Fig. 2

Intraoperative finding revealed an ileosigmoid knot was identified, a complex volvulus in which the distal ileum twisted around the sigmoid colon in a clockwise direction. This resulted in strangulation of both bowel segments, leading to gangrenous changes in the affected ileum and sigmoid colon.