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Introduction

Bowel obstruction in general is common cause for acute abdomen which most of the time needs emergency surgical intervension. Small bowel obstruction is the commonest cause worldwide. There are a lot of causes of small bowel obstruction [1, 2]. Among these, post-operative adhesion, hernia and malignancies are the most 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 appendicoileal are rare causes of bowel obstruction [12]. Among these appendicoileal knotting is the rarest to be occurred in bowel obstruction [3, 4]. Since 1901 of the 1st documented report there are few handful of cases reported in literatures [13]. 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 [6, 7].

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

Case Presentation

This is a 28 yrs 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= 90/60 mmgh, PR=112 Bpm of tachycardia, RR=21 Breath/min, T=36.9, PSO2= 96% off oxygen. On physical examination there was dry bucal 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. Labratory investigation came with CBC= 16000, 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 entery 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 the was long non inflamed appendex rapped around the distal segment of the ileum near to the ileocecal junction, the tip of the appendex was buried to the ileal mesentery otherwise it was intact and no fecolith in it (Figure 1). Then the appendex released from around the entrapped distal ileal segment which was in double segment obstruction. Then after appendectomy done, the discoloured ileal segment rapped by warm saline soaked sterile surgical pack and time taken. Later the peristalysis and colour of the enterapped 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 4th day and came 2 weeks later for follow in stable condition.

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. This leads to most diagnoses being made intra-operatively, often as a "surprise" finding during exploratory laparotomy [15, 16].

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 [1-10].

Histopathological findings, when available, sometimes reveal an associated mucocele of the appendix [1, 9].These findings suggested that certain appendiceal pathologies might contribute to the knotting mechanism. In most cases appendicitis was mentioned as a preceding incident to appendicoileal knotting. Yet, there is one report that reveal the occurrence of appendicoileal knotting in the presence of macroscopically and microscopically healthy looking appendex [8]. Our case also presented with the same finding with this, supporting the occurence of appendicoileal knotting in the abscence of preceding appendicitis. 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 [11, 14, 15].

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.

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 andansthetists.

Fund

No fund for this case report.

Informed Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

N/A

Conflict of Interest

No conflict of interest.

Data Availability

All relevant data are within the paper and its Supporting Information files.