Ileocecal Knotting Causing Intestinal Obstruction on Early Postpartum Period: Case Report

Intestinal knotting syndromes are rare causes of mechanical bowel obstruction, ileo-sigmoid knotting being the most common type. Ileocecal knotting is the rarest type among knot syndromes and there are few case reports across the world.

We present a case of ileocecal knotting in a postpartum patient with abdominal distention, vomiting and failure to pass feces and flatus. Plain abdominal radiograph revealed dilated small bowel loops with multiple air fluid levels. Exploratory laparotomy was performed with intra-operative finding of ileocecal knotting with viable bowel, mobile cecum and ascending colon and gangrenous tip of appendix. We untied the knot and performed an appendectomy. Due to intra-operative instability of the patient's vital signs, right hemicolectomy was differed and cecum as well as ascending colon were fixed to right posterolateral abdominal wall.

Ileocecal knotting is a very rare finding, and few case reports have been published. The intra-operative findings of the mobile cecum and ascending colon are consistent with previous reports and it is a predisposing factor for knot besides low BMI and young age of our patient. Surgical management is dictated by intra-operative conditions such as viability of the bowel, intra-operative stability of the patient, extent of resection and length of the remaining bowel. Surgical options include en bloc resection of knot with gangrenous bowel and end to end anastomosis or end ileostomy with closure of distal end.

Ileocecal knotting should be considered as a differential diagnosis for patients presenting with intestinal obstruction with unusual radiographic findings. Early diagnosis and prompt surgical intervention prevents bowel infarction and enhance the prognosis. Preoperative abdominal CT scan is helpful in such cases with unusual radiographic findings.