Appendico ilial knotting: a rare cause of small bowel obstruction

Appendico ilial knotting: a rare cause of small bowel obstruction Small bowel obstruction (SBO) is one of the most common acute surgical conditions that needs immediate innervation to prevent the morbidity and mortality associated with it. The common causes of SBO are different in developed and develop- ing nations. Well-versed knowledge of the rare causes of SBO including its option of management is necessary. In this art- icle, we present a case of an acute SBO secondary to Appendico-ileal knotting. The diagnostic difficulty and the options of management are discussed for last 4 months which increased since the onset of cramp. On INTRODUCTION physical examination, she was tachycardia to the level of 110 Small bowel obstruction (SBO) is one of the common acute beats per minute, BP 110/70 and she was maintaining her satur- abdomen with different causes. Management of SBO needs ation on atmospheric oxygen-97%. Her temperature 37.2°C, her through knowledge of the pathophysiology and causes of abdomen was distended with hyperactive bowel sound, hyper obstruction. The commonest causes include Adhesive SBO, tympanic to percussion and no tenderness. On digital rectal Hernia, volvulus and malignancies [1–3] appendix as a cause of examination, normal anal tone with empty rectum and no mechanical SBO has been well known since 1901 [4]. this has blood on examining finger. On investigation, she has WBC been described in literatures with different names; appendico- count of 10 600 with neutrophil 86%, She was referred from pri- ilial knotting, appendicular tourniquet, appendicular knot and vate setup with abdominal ultrasound which shows significant appendiceal tie syndrome [4–7]. It is difficult to make the diag- dilation of bowel loops with increased peristaltic activity and nosis preoperatively as the patients present as SBO. The subse- right lower quadrant blind ending tubular structure with diam- quent management is dictated by the intra operative finding. eter of 18 mm with hypoechoic content. On plain abdominal X-ray shows dilated small bowel loops with multiple air fluid level. (Fig. 1) CASE REPORT With the diagnosis SBO secondary to adhesion band, the A 46-year-old-female patient presented with crampy abdom- patient was taken to the operation room after and the finding inal pain of a week duration. Associated with vomiting of was dilated small bowel loops with closed loop obstruction at ingested matter which latter become bilious matter. She does distal 8 cm of ilium by appendicular knot. At the tip of the not pass faeces but passes flatus. She has abdominal distention appendix there is 4×2 cm cystic mass with no solid component. Received: March 27, 2018. Accepted: April 18, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A.T. Kifle and S. Tesfaye Retrograde appendectomy including mesoappenix done (Fig. 2). obstruction, partial or complete, simple, or complicated [2]. The biopsy result is mucions cyst adenoma with no extension Mechanical SBO has many etiologist, post-op adhesion being in the surrounding mesoapppendix and the base of the appen- top in the developed countries. Soressa et al.’s study [1]in dix. (Fig. 3) There was a pressure mark exactly at the ileocecal Ethiopia post-op adhesion and groyne hernia are the common- junction and 8 cm away from it. Post-operatively, the patient est cause of SBO. Other common etiologist includes post-op started sips on second day discharged on fifth day with post- adhesion and small bowel malignancies [1, 3]. operative diagnosis of SBO secondary to appendico-ilial knot- Appendicitis as a cause of SBO has been known in the litera- ting with appendicular mucocele. ture since 1901 when Lucius Hotchkiss reported three success- ful surgeries for intestinal obstruction due to appendicitis [4]. Bhandari et al. has reviewed the literature and proposed four categories on the pathology of appendicitis causing obstruction; DISCUSSION adynamic, mechanical (without strangulation), strangulation of Acute SBO is one of the most common surgical clinical pro- intestine and intestinal obstruction due to mesenteric ischae- blems. It can be classified based on many factors: functional or mia [8]. mechanical, the small bowel (SBO) or large bowel (LBO) Strangulation can be due to the appendix wrapping around the base of a bowel loop, or when inflamed appendix adheres to caecum, small intestine or posterior peritoneum and a part of the bowel herniates through the gap. This is described with appendicular KNOT, appendicular tourniquet, appendiceal tie syndrome and appendico-ilial knotting [6, 7, 9, 10]. in our opinion, appendico-ilial knotting is the preferred name because it describes the pathologies of both appendix and ilium. Diagnosis of SBO is made based on history and physical examination. The four-cardinal sign and symptoms are colicky abdominal pain, vomiting, absolute constipation, and abdom- inal distension [6]. As depicted in the table, most of the patients with appendico-ilial knotting presented with abdominal pain, vomiting and constipation [4–10] Chatterjee suggest that a peri- od of acute appendicitis precedes the mechanical obstruction. CT scan of abdomen can suggest the diagnosis preoperatively. But as the patients are having acute abdomen, emergent exploratory laparotomy is indicated and it will confirm the diagnosis. The management depends on the extent of the strangula- tion and part of bowel involved. It ranges from appendectomy to right hemicolectomy. In our case, the appendix was gangren- ous with viable distal ilium so appendectomy was done. The mucocele associated with our case can be ascribed to chronic Figure 1: Erect abdominal X-ray showing multiple air fluid level with dilated retention mucus. small bowel loops. Figure 2: Appendix with mucocele entangling distal ilium forming closed loop obstruction (blue arrow—appendicular knot, orange—entangled distal ilium, green— the pressure mark on the distal ilium and yellow—gangrenous appendicular mucocele). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Appendico ilial knotting 3 Figure 3: (A) Post-appendectomy gangrenous appendix with mucocele, (B) and (C). Histologic specimen per low power and high power field microscopy showing appendicular mucocele with some haemorrhagic infracts with thinned out mucosa and no extension beyond the submucosa. 4. Hotchkiss Lucius W. Acute intestinal obstruction following CONCLUSION appendicitis. A report of three cases successfully operated Appendico ilial knotting is a rare cause of mechanical SBO. As a upon. Ann Surg 1901;34:660–77. surgeon dealing with acute abdomen in day to day practise, 5. O’Donnell ME, Sharif MA, O’Kane A, Spence RA. Small bowel knowledge about the diagnosis and management of this rare obstruction secondary to an appendiceal tourniquet. Ir J diagnosis is very helpful. Med Sci 2009;178:101–05. 6. Ranjan A, Kumari K, Jha S. Acute small bowel obstruction as a result of an appendicular knot encircling the terminal CONFLICT OF INTEREST STATEMENT ileum:an exceptionally rare case report. Int J Med Sci Public Health 2015;4:426–9. None declared. 7. Awale L, Joshi BR, Rajbanshi S, Adhikary S. Appendiceal tie syndrome: a very rare complication of a common disease. World J Gastrointest Surg, 27 2015;7:67–70. REFERENCES 8. Mohandas PG, Bhandari L. Appendicitis as a cause of intes- 1. Soressa U, Mamo A, Hiko D, Fentahun N. Prevalence, causes tinal strangulation: a case report and review. World J Emerg and management outcome of intestinal obstruction in Surg 2009;4:34. Adama Hospital, Ethiopia. BMC Surg 2016;16:38. 9. Yang AD, Lee C-H. Appendico-ileal knotting resulting in 2. Holzheimer RG, Mannick JA. Surgical Treatment: Evidence- closed-loop obstruction in a child. Pediatr Radiol 2002;32: Based and Problem-Oriented. Munich: Zuckschwerdt, 2001. 879–81. 3. Tsegaye S, Osman M, Bekele A. Surgically treated acute 10. Chowdary PB, Shivashankar SC, Gangapp RB, Varghese EV. abdomen at Gondar University Hospital, Ethiopia. East Cent Appendicular tourniquet: a cause of intestinal obstruction. Afr J Surg 2006;12:53–7. J Clin Diagn Res 2016;10:9–11. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Appendico ilial knotting: a rare cause of small bowel obstruction

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Abstract

Small bowel obstruction (SBO) is one of the most common acute surgical conditions that needs immediate innervation to prevent the morbidity and mortality associated with it. The common causes of SBO are different in developed and develop- ing nations. Well-versed knowledge of the rare causes of SBO including its option of management is necessary. In this art- icle, we present a case of an acute SBO secondary to Appendico-ileal knotting. The diagnostic difficulty and the options of management are discussed for last 4 months which increased since the onset of cramp. On INTRODUCTION physical examination, she was tachycardia to the level of 110 Small bowel obstruction (SBO) is one of the common acute beats per minute, BP 110/70 and she was maintaining her satur- abdomen with different causes. Management of SBO needs ation on atmospheric oxygen-97%. Her temperature 37.2°C, her through knowledge of the pathophysiology and causes of abdomen was distended with hyperactive bowel sound, hyper obstruction. The commonest causes include Adhesive SBO, tympanic to percussion and no tenderness. On digital rectal Hernia, volvulus and malignancies [1–3] appendix as a cause of examination, normal anal tone with empty rectum and no mechanical SBO has been well known since 1901 [4]. this has blood on examining finger. On investigation, she has WBC been described in literatures with different names; appendico- count of 10 600 with neutrophil 86%, She was referred from pri- ilial knotting, appendicular tourniquet, appendicular knot and vate setup with abdominal ultrasound which shows significant appendiceal tie syndrome [4–7]. It is difficult to make the diag- dilation of bowel loops with increased peristaltic activity and nosis preoperatively as the patients present as SBO. The subse- right lower quadrant blind ending tubular structure with diam- quent management is dictated by the intra operative finding. eter of 18 mm with hypoechoic content. On plain abdominal X-ray shows dilated small bowel loops with multiple air fluid level. (Fig. 1) CASE REPORT With the diagnosis SBO secondary to adhesion band, the A 46-year-old-female patient presented with crampy abdom- patient was taken to the operation room after and the finding inal pain of a week duration. Associated with vomiting of was dilated small bowel loops with closed loop obstruction at ingested matter which latter become bilious matter. She does distal 8 cm of ilium by appendicular knot. At the tip of the not pass faeces but passes flatus. She has abdominal distention appendix there is 4×2 cm cystic mass with no solid component. Received: March 27, 2018. Accepted: April 18, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A.T. Kifle and S. Tesfaye Retrograde appendectomy including mesoappenix done (Fig. 2). obstruction, partial or complete, simple, or complicated [2]. The biopsy result is mucions cyst adenoma with no extension Mechanical SBO has many etiologist, post-op adhesion being in the surrounding mesoapppendix and the base of the appen- top in the developed countries. Soressa et al.’s study [1]in dix. (Fig. 3) There was a pressure mark exactly at the ileocecal Ethiopia post-op adhesion and groyne hernia are the common- junction and 8 cm away from it. Post-operatively, the patient est cause of SBO. Other common etiologist includes post-op started sips on second day discharged on fifth day with post- adhesion and small bowel malignancies [1, 3]. operative diagnosis of SBO secondary to appendico-ilial knot- Appendicitis as a cause of SBO has been known in the litera- ting with appendicular mucocele. ture since 1901 when Lucius Hotchkiss reported three success- ful surgeries for intestinal obstruction due to appendicitis [4]. Bhandari et al. has reviewed the literature and proposed four categories on the pathology of appendicitis causing obstruction; DISCUSSION adynamic, mechanical (without strangulation), strangulation of Acute SBO is one of the most common surgical clinical pro- intestine and intestinal obstruction due to mesenteric ischae- blems. It can be classified based on many factors: functional or mia [8]. mechanical, the small bowel (SBO) or large bowel (LBO) Strangulation can be due to the appendix wrapping around the base of a bowel loop, or when inflamed appendix adheres to caecum, small intestine or posterior peritoneum and a part of the bowel herniates through the gap. This is described with appendicular KNOT, appendicular tourniquet, appendiceal tie syndrome and appendico-ilial knotting [6, 7, 9, 10]. in our opinion, appendico-ilial knotting is the preferred name because it describes the pathologies of both appendix and ilium. Diagnosis of SBO is made based on history and physical examination. The four-cardinal sign and symptoms are colicky abdominal pain, vomiting, absolute constipation, and abdom- inal distension [6]. As depicted in the table, most of the patients with appendico-ilial knotting presented with abdominal pain, vomiting and constipation [4–10] Chatterjee suggest that a peri- od of acute appendicitis precedes the mechanical obstruction. CT scan of abdomen can suggest the diagnosis preoperatively. But as the patients are having acute abdomen, emergent exploratory laparotomy is indicated and it will confirm the diagnosis. The management depends on the extent of the strangula- tion and part of bowel involved. It ranges from appendectomy to right hemicolectomy. In our case, the appendix was gangren- ous with viable distal ilium so appendectomy was done. The mucocele associated with our case can be ascribed to chronic Figure 1: Erect abdominal X-ray showing multiple air fluid level with dilated retention mucus. small bowel loops. Figure 2: Appendix with mucocele entangling distal ilium forming closed loop obstruction (blue arrow—appendicular knot, orange—entangled distal ilium, green— the pressure mark on the distal ilium and yellow—gangrenous appendicular mucocele). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Appendico ilial knotting 3 Figure 3: (A) Post-appendectomy gangrenous appendix with mucocele, (B) and (C). Histologic specimen per low power and high power field microscopy showing appendicular mucocele with some haemorrhagic infracts with thinned out mucosa and no extension beyond the submucosa. 4. Hotchkiss Lucius W. Acute intestinal obstruction following CONCLUSION appendicitis. A report of three cases successfully operated Appendico ilial knotting is a rare cause of mechanical SBO. As a upon. Ann Surg 1901;34:660–77. surgeon dealing with acute abdomen in day to day practise, 5. O’Donnell ME, Sharif MA, O’Kane A, Spence RA. Small bowel knowledge about the diagnosis and management of this rare obstruction secondary to an appendiceal tourniquet. Ir J diagnosis is very helpful. Med Sci 2009;178:101–05. 6. Ranjan A, Kumari K, Jha S. Acute small bowel obstruction as a result of an appendicular knot encircling the terminal CONFLICT OF INTEREST STATEMENT ileum:an exceptionally rare case report. Int J Med Sci Public Health 2015;4:426–9. None declared. 7. Awale L, Joshi BR, Rajbanshi S, Adhikary S. Appendiceal tie syndrome: a very rare complication of a common disease. World J Gastrointest Surg, 27 2015;7:67–70. REFERENCES 8. Mohandas PG, Bhandari L. Appendicitis as a cause of intes- 1. Soressa U, Mamo A, Hiko D, Fentahun N. Prevalence, causes tinal strangulation: a case report and review. World J Emerg and management outcome of intestinal obstruction in Surg 2009;4:34. Adama Hospital, Ethiopia. BMC Surg 2016;16:38. 9. Yang AD, Lee C-H. Appendico-ileal knotting resulting in 2. Holzheimer RG, Mannick JA. Surgical Treatment: Evidence- closed-loop obstruction in a child. Pediatr Radiol 2002;32: Based and Problem-Oriented. Munich: Zuckschwerdt, 2001. 879–81. 3. Tsegaye S, Osman M, Bekele A. Surgically treated acute 10. Chowdary PB, Shivashankar SC, Gangapp RB, Varghese EV. abdomen at Gondar University Hospital, Ethiopia. East Cent Appendicular tourniquet: a cause of intestinal obstruction. Afr J Surg 2006;12:53–7. J Clin Diagn Res 2016;10:9–11. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy088/4993410 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Published: May 2, 2018

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