Ileoileal knotting as a rare cause of acute gangrenous small bowel obstruction and its diagnostic challenge: a rare case report

Introduction and importance: Ileoileal knotting is an exceptionally rare and life-threatening cause of acute intestinal obstruction. It involves two loops of ileum twisting around each other, creating a double closed-loop obstruction that rapidly progresses to gangrene. There is limited data on ileoileal knotting, rendering its pre-operative diagnosis almost infeasible and its etiology poorly comprehended. Case presentation: A 23-year-old male presented with a 20-hour history of severe, progressive abdominal pain, vomiting, distension, and obstipation. He was tachycardic and hypotensive, with physical signs of generalized peritonitis. Emergency laparotomy revealed approximately 120 cm of gangrenous ileum formed by an ileoileal knot. The involved segment was resected. Due to the extremely short length (5 cm) of the remaining viable terminal ileum, a right hemicolectomy with an ileo-transverse anastomosis was performed. Clinical discussion: Ileoileal knotting is a rare subset of intestinal knotting syndromes. Its etiology is poorly understood but is thought to involve hyper-mobile bowel with a long mesentery and vigorous peristalsis. The decision to untie the knot versus perform an en-bloc resection is debated. In this case, untying was attempted but ultimately necessitated a right hemi-colectomy due to non-viability of the terminal ileum. The patient’s outcome was favorable, likely due to prompt surgical intervention and adequate small bowel reserve. Conclusion: Ieoileal knotting is a surgical emergency that is almost always diagnosed intra-operatively. A high index of suspicion for rare causes of bowel obstruction is crucial. Immediate resuscitation and exploratory laparotomy are life-saving. The choice of surgical procedure must be tailored to the viability of the bowel and the patient’s condition.