Abstract / Summary
Abstract Background: Appendico-ileal knotting is a rare cause of closed-loop small-bowel obstruction in which the appendix encircles the ileum and may cause strangulation and bowel ischemia. Preoperative diagnosis is difficult because the clinical presentation is nonspecific. Case presentation: A 52-year-old Ethiopian man with no prior abdominal surgery presented after 2 days of abdominal pain, distension, bilious vomiting, and obstipation. He was hypotensive, tachycardic, dehydrated, and had generalized peritonitis. Plain abdominal radiography showed features of small-bowel obstruction. Following resuscitation, antibiotics, and vasopressor support, emergency laparotomy was performed for suspected strangulated small-bowel obstruction. Approximately 2 L of hemorrhagic intraperitoneal fluid was found. A 16-cm inflamed appendix tightly encircled the distal ileum, forming an Appendico-ileal knot and causing approximately 1 m of ileal gangrene. The knot was released, appendectomy and ileal resection were performed, and intestinal continuity was restored with an end-to-side ileo-transverse anastomosis. The patient required postoperative intensive care and vasopressor support; shock resolved by postoperative day 2. He was discharged on postoperative day 7 and remained well through postoperative day 30. Conclusions: Appendico-ileal knotting is a rare cause of closed-loop small-bowel obstruction that may be encountered intraoperatively among unusual causes of strangulation, including in patients with a virgin abdomen. Hemodynamic instability, peritonitis, and suspected bowel ischemia warrant urgent operative assessment; CT should not delay operative source control in an unstable patient.