Appendico-Ileal Knotting: A Rare, Dangerous, and Often Overlooked Complication of Appendicitis: A Case Report

Appendicitis and small bowel obstruction (SBO) are common causes of acute abdomen encountered in clinical practice. However, appendicitis as a cause of SBO is very rare and often overlooked, commonly resulting in delayed diagnosis and management. Appendico-ileal knotting, a rare but dangerous way appendicitis could lead to mechanical SBO, occurs when an inflamed appendix forms a ring-like structure through which a small bowel loop herniates, resulting in closed-loop obstruction that could be complicated by small bowel strangulation and gangrene if not identified and intervened early. Preoperative diagnosis of appendico-ileal knotting is very challenging, with most cases diagnosed intraoperatively. We present a case of a 35-year-old female who presented with crampy abdominal pain of 2 days duration associated with vomiting, abdominal distension, and constipation. Blood pressure was unrecordable, and abdominal examination was positive for diffuse guarding, rigidity, and rebound tenderness. A plain abdominal X-ray revealed multiple centrally located air-fluid levels, after which she was diagnosed with SBO and taken to the operating room for exploratory laparotomy. With the intraoperative finding of appendico-ileal knotting complicated by distal ileal gangrene, she was managed with appendectomy, ileal resection, and end ileostomy. Appendico-ileal knotting is a very rare condition with a limited number of case reports in the existing literature. This case report aims to contribute to a better understanding of this condition and emphasize the significance of early identification and intervention in reducing the substantial risk of morbidity and mortality associated with the condition if not managed timely.