|Year : 2013 | Volume
| Issue : 2 | Page : 50-52
The "small" wrapping around the "large"!
Santosh Rai1, Manohar Pai2, Adurthy Priyanka1, Irshad Mohammed2
1 Department of Radiodiagnosis, KMC Mangalore, Manipal University, Manipal, Karnataka, India
2 Department of Surgery, KMC Mangalore, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||15-Jan-2014|
Department of Radiodiagnosis, KMC Mangalore, Manipal University, Manipal, KarnatakaDepartment of Radiodiagnosis, KMC Mangalore, Manipal University, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
This is a case report of a 32-year-old female who presented with acute intestinal obstruction. The radiological diagnostic possibilty of midgut volvulus with ileo-sigmoid knotting and obstruction of the proximal sigmoid colon and small bowel was given. The diagnosis was confirmed intra-operatively with associated gangrene of the distal jejunum and proximal ileum. Resection of the gangrenous segments of bowel and the release of ileo-sigmoid knotting was performed. The literature about the ileo-sigmoid knot was reviewed. It may be difficult to diagnose this condition before surgery. This is a surgical emergency that requires urgent resection of gangrenous bowel and untwisting of the volvulus. The aim of this short communication is to increase awareness of the pre-operative computed tomography (CT) diagnosis of this condition.
Keywords: Computed tomography scan, ileo-sigmoid knotting, intestinal obstruction, volvulus
|How to cite this article:|
Rai S, Pai M, Priyanka A, Mohammed I. The "small" wrapping around the "large"!. Saudi Surg J 2013;1:50-2
| Introduction|| |
An ileosigmoid knot is a type of intestinal obstruction in which distal small bowel wraps around the base of the sigmoid colon and passes beneath itself forming a knot.  Patients usually present with clinical features of colonic obstruction. Vomiting, abdominal distension, abdominal pain, and blood-stained stools are frequent symptoms. It may be difficult to diagnose this condition before surgery. This is a surgical emergency that requires urgent resection of gangrenous bowel and untwisting of the volvulus.
| Case Report|| |
A 32-year-old female patient reported to Emergency department with abdominal pain and distension. The patient had vomiting for 4 episodes which was non-bilious. The patient had passed normal stools the previous day. On examination the patient was oriented and conscious but looking ill. The patient had tachycardia, however temperature and blood pressure were normal. Per rectal examination showed no faecal material in the rectum and no polypoidal mass lesion. On examination there was significant abdominal distension present with diffuse tenderness and rebound tenderness. On ultrasonographic examination there was significant bowel distension and moderate ascites. The X-ray erect abdomen showed multiple air fluid levels, predominantly central suggesting small bowel dilatation.
The axial CT sections of the abdomen [Figure 1] with some amount of oral and rectal contrast revealed redundant and dilated sigmoid colon and loss of haustrae. There is swirling of the mesentery and mesenteric vessels. Also noted were dilatation of the jejunal loops and proximal ileal loops. The Caecum and ileocaecal junction was medially displaced. The descending colon and the cecum was displaced medially giving a medial beak appearance. The small bowel loops were noted lying lateral to the colonic loops. A provisional diagnosis of midgut volvulus with ileosigmoid knotting was given.
|Figure 1: Axial computed tomography scan abdomen images (arranged clockwise) shows medial deviation of the cecum with a pointed medial border (wide white arrow) with distal ileum looping around the sigmoid colon; small bowel loops lying lateral to the colon (bent arrow). The ileo-sigmoid knot is seen (white arrow head) and a further caudal CT scan shows fluid-filled ileal loops in the pelvis (long white arrow) and dilated ahaustral sigmoid colon (curved arrow). Caudal computed tomography scan section shows the whirl sign (star sign) created by the twisted mesentery and bowel). Black arrowhead shows the transition between the dilated and collapsed ileum|
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The patient was immediately taken up for surgery in the early hours of the night. Intra-operatively [Figure 2] there was moderate hemoperitoneum. The distal jejunum and proximal ileum was gangrenous. The distal ileum was seen wrapped around the redundant sigmoid. The sigmoid colon was in closed loop obstruction but was not ischemic or gangrenous. The sigmoid coon was untwisted and knot was released and resection of the gangrenous segment was performed and anastomosis done between mid jejunum and distal ileum. The patient dramatically improved and was discharged on the ninth post operative day.
|Figure 2: Intra-operative photographs show the gangrenous and dilated small bowel loops (straight white arrow) and the ileo-sigmoid knot (curved white arrow)|
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| Discussion|| |
The exact cause of this condition is not known. , Machado NO reviewed 280 cases reported in English literature in which are described three factors that are responsible for the ileosigmoid knot: A long small bowel mesentery and freely mobile small bowel; a long sigmoid colon on a narrow pedicle; and finally the ingestion of a high bulk diet in the presence of an empty small bowel. 
Ileosigmoid has been described into three types. In type I, the ileum wraps itself around the sigmoid colon in a clockwise or anticlockwise direction. In type II, the sigmoid colon wraps itself around a loop of ileum in a clockwise or anticlockwise direction. In type III, the ileocecal segment wraps itself around the sigmoid colon. It has been predominantly reported form Central African and Asian populations with a mean age of presentation about 40 years.
The obstruction progresses into gangrene of the ileum and the sigmoid colon and increases the incidence of morbidity and mortality.
CT scan may show medial deviation of the distal descending colon, with a pointed appearance of its medial border, which is a distinct feature of the ileosigmoid knot.  Similarly, the cecum may show medial deviation due to the tightly stretched terminal ileum between the sigmoid mesocolon and the cecum. The "whirl sign" which is actually the vascular structures converging toward the sigmoid colon also indicates the diagnosis.  CT scan may also show signs of bowel ischemia. Concurrent ischemic changes in the ileal loops and sigmoid colon should alert the radiologist. The presence of the whirl sign, medially deviated distal descending colon and cecum, and mesenteric vascular structures from the superior mesenteric vessels that converge toward the sigmoid colon on CT scan help clinch the diagnosis. ,,
Ileosigmoid knotting is different from any simple volvulus as it is a medical and surgical emergency.
| Conclusion|| |
The ileosigmoid knot is a rare but life-threatening cause of closed-loop intestinal obstruction. Preoperative CT scan diagnosis and prompt treatment can lead to a good outcome. Findings of simultaneous ileal and sigmoid ischemia with non-ischemic colon interposed in between should, in an appropriate clinical setting, indicate this condition. The aim of this short communication is further raise awareness of this surgical emergency as with other reports in literature.  The principal aim is to achieve early and effective resuscitation followed by emergency surgery,  where in the gangrenous segment is removed and anastomosis is performed and hence the crux lies in early and prompt diagnosis.
| References|| |
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[Figure 1], [Figure 2]