Ileosigmoid knotting: A rare cause of acute intestinal obstruction and peritonitis

Abstract

Introduction: Ileosigmoid knotting (ISK) is one of the rarer causes of bowel obstruction compared to others. This is also called compound volvulus or double loop obstruction. The presentation symptoms are similar to those of other large bowel or distal intestinal obstructions. But the pathogeny’s or disease’s progression is rapid. So the patient develops ischemia or strangulation of the involved segment of the bowel earlier than the sigmoid or ceal volvulus. One of the challenges of the disease is that, especially in low-income countries like ours, there is no access to contrast computed tomography (CT), which is more sensitive diagnostic imaging. Case Report: A 58-year-old male patient presented to our hospital with abdominal pain for two days. He was referred from the primary hospital. The pain was initially central and later diffused to other parts of the abdomen. Associated with this, he was vomiting of ingested matter for more than two episodes. On physical examinations, he was in acute pain, and his vital signs showed a pulse rate of tachycardia at 127 BPM. On abdominal examination, he had distention and diffused tenderness with gardening. So we diagnosed him with peritonitis secondary to gangrenous sigmoid volvulus obstruction (SVO). So I chose the imaging that is available in our hospital, a plain abdominal X-ray. So the patient was resuscitated with normal saline, an antibiotic was initiated, and he was taken to the operation after giving consent. The ilium and sigmoid colon were gangrened and en bloc resection was done, and the jejunum and remaining 7 cm of ilium from the ileocecal valve were anastomosed. The patient was taken to or for a relook, and the anastomosis was disrupted, then refreshed, and both the proximal and distal segments were taken out as stomas. The output was significant and later developed a controlled entrocutaneous fistula, which was closed after three weeks. Conclusion: The prognosis is poor for ISK compared to other common types of volvulus and worse prognosis challenging management in conditions with both active and passive bowel ischemia which happened to our patients. Diagnosis is also challenging before the surgery. The abdominal X-ray and ultrasound are available and commonly the surgeon commonly will not send for this unless the patient is stable. Blind rectal tube deflation the common intervention in our setup with no access for sigmoidoscopy is not indicated for this non-surgical initial management rather with a highly suspicious diagnosis early resuscitation with early surgical treatment.