Appendico-Ileal Knotting a Rare Cause of Small Bowel Obstruction; Case Report and Literature Review from Leku General Hospital, Ethiopia

Abstract

Small bowel obstruction is the common cause of acute abdomen for which emergency surgical intervention is mandatory. Bowel knotting’s like ileo-sigmoid knotting, ileo-ileal knotting, ileocecal knotting and appendico-ileal knotting’s are rare occurrences as a cause of obstruction. Among these appendico-ileal knotting is by far the rarest cause of obstruction. Since its 1^st report in 1901, there are case reports of this scenario but all associated it with the presence of appendicitis. We report a 28yrs old female patient who presented with sign symptom of small bowel obstruction for whom appendico-ileal knotting is identified with healthy looking appendix rapped around the distal ileum which was a near miss bowel segment which later returned healthy after the appendix release and warm saline socked sterile pack rapped for a minute. Appendico-ileal knotting can occur in the absence of preceding appendicitis.

Keywords: Bowel obstruction, Appendicitis, Appendicoileal knotting, Double loop obstruction, Intraoperative surprise

1. Introduction

Bowel obstruction in general is common cause for acute abdomen which most of the time needs emergency surgical intervention. Small bowel obstruction is the commonest cause worldwide. There are a lot of causes of small bowel obstruction^1,2. post-operative adhesion, hernia and malignancies are the commonest causes to mention worldwide. But small bowel volvulus is the commonest in most part of our country Ethiopia. Bowel knotting like ileosigmoid, ileoileal, ileocecal and appendico-ileal are rare causes of bowel obstruction³. Among these appendico-ileal knotting is the rarest to be occurred in bowel obstruction^4,5. Since 1901 of the 1^st documented report there are few handfuls of cases reported in literatures⁶. Appendicoileal knotting is rapping of the appendex over the segment of distal ileum which causes closed loop obstruction. If untreated or delayed, it results in bowel vascular compromise and eventual bowel ischemia. Preoperative diagnosis is challenging since it has no pathognomonic features but mimic other intestinal obstruction causes of clinical presentations. Preoperative imaging, including Computed Tomography (CT), has shown potential utility, but its accuracy is limited and in resource limited setups its accessibility is ambitious^7,8.

This case report adds another literature asset to the existing handful of cases world-wide with some peculiarities of uninflamed appendix causing appendico-ileal knotting in 28yrs old female patient.

2. Case Presentation

This is a 28yrs old female patient who presented to emergency room with the complain of abdominal pain of 3 days duration. She complained that she has crampy abdominal pain which started at the periumblical area. In associated to this she had repeated episode of bilious type of vomiting, failure to pass fecess and flatus. For this complain she had been taken to her nearby private clinic and analgesics were given. But inspite of this her complain worsened and abdominal distension also started. She has no previous medical and surgical histories. She has 3 children and currently she is using family planning method. She had no vaginal bleeding, no vaginal discharge and no history of trauma.

Upon presentation she was acute sick looking with BP =90/60mmgh, PR=112Bpm of tachycardia, RR=21Breath/min, T=36.9, PSO2=96% off oxygen. On physical examination there was dry buccal mucosa, dry tongue and on abdominal examination there was abdominal distension with hypertympanicity on percussion, there was also minimal tenderness upon palpation. Digital rectal examination revealed empty rectum. Laboratory investigation came with CBC=16,000, Hgb=12g/dl, PLT=250000, RBS=150, Imaging suggested with multiple air fluid levels with preoperative diagnosis of SBO secondary to small bowel volvulus. For this diagnosis patient prepared for exploratory laparotomy. Medline abdominal incision used to open the abdominal cavity. Upon entry to the abdominal cavity there was moderately hemorrhagic free peritoneal fluid comes out and there was multiple small bowel loops distended, near to ischemia, especially the distal ileal segment. Surprisingly she was long non-inflamed appendix rapped around the distal segment of the ileum near to the ileocecal junction, the tip of the appendix was buried to the ileal mesentery otherwise it was intact and no fecalith in it (Figure 1). Then the appendix released from around the entrapped distal ileal segment which was in double segment obstruction. Then after appendectomy done, the discolored ileal segment rapped by warm saline-soaked sterile surgical pack and time taken. Later the peristalsis and color of the entrapped bowel segment returned normal. After meticulous observation of all segment of the small bowel, colon and other solid organ, no pathology witnessed then abdomen closed in layer and patient awaken and left OT stable. Her post operation course was uneventful; she discharged home on the 4^th day and came 2 weeks later for follow in stable condition.

Figure 1: Intraoperative finding of appendico-ileal knotting.

3. Discussion

Appendico-ileal knotting remains an exceedingly rare cause of Small Bowel Obstruction (SBO), often presenting a significant diagnostic challenge. As evidenced by the collected case reports, the condition lacks a pathognomonic clinical presentation, with symptoms typically overlapping with other, more common, causes of SBO, such as volvulus, adhesions or hernias (Table 1). This leads to most diagnoses being made intra-operatively, often as a “surprise” finding during exploratory laparotomy^9,10.

Table 1: Summarized tables of few case reports of appendicoileal knotting.

The patient demographic in these cases varies widely, spanning from pediatric patients to the elderly. The specific pathophysiology depends on an elongated, mobile appendix, which can become inflamed and form a constricting band around a loop of the ileum. The outcome is critically dependent on the timing of surgical intervention. Early intervention, as seen in cases where the bowel remains viable, allows for a straightforward procedure involving the untwisting of the knot and appendectomy. In contrast, delayed presentation or diagnosis, especially in resource-limited settings, can lead to catastrophic complications such as bowel gangrene, perforation and septic shock, requiring more extensive and complex procedures, such as bowel resection and anastomosis^{1,2,4,5,7,8,11-14}.

Histopathological findings, when available, sometimes reveal an associated mucocele of the appendix, as noted in the cases by Mandal, et al.¹ and Alemu, et al.¹². This finding suggests that certain appendiceal pathologies might contribute to the knotting mechanism. In most cases appendicitis was mentioned as a preceding incident to appendicoileal knotting. Yet, only Klein, et al.⁸ reported the occurrence of appendico-ileal knotting in the presence of macroscopically and microscopically healthy looking appendex. Our case also presented with the same finding with Klein, et al.⁸ report. So, appendix can be a cause for small bowel obstruction in the presence of its inflammation or only mechanically as a band in the absence of its inflammation. There are two basic situations where the appendix may also cause a mechanical obstruction appendicular tip attached to the mesentery surrounding an ileal loop, producing compression of its lumen and the appendicular tip attached to the intestinal serosa, producing the obstruction by direct compression or torsion of a loop. The overall literature emphasizes that while appendico-ileal knotting is a rare event, a high index of clinical suspicion is necessary in patients presenting with SBO, especially in the absence of a clear etiology like a history of prior surgery. Early diagnosis and prompt surgical management are the cornerstones of successful treatment and significantly improve patient outcomes. But the overall management depends on the viability of the bowel or strangulation^9,15,16,.

4. Conclusion

Appendico ileal knotting is still rare cause for small bowel obstruction. But as abdomen is “a Pandora box” the very rare things can happen and clinical suspicion is needed. Early diagnosis may help the patient for early surgical intervention. Appendico ileal knotting can occur in the absence of appendicitis.

5. Acknowledgement

We would like to thank all Leku General Hospital clinical staffs who are involved in the management of the patient specially to the operating theater nurses and anesthetists.

6. References

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