Ekehorn () and Faltin () in their studies classified the ileosigmoid knot according to bowel involved and arrangement of loops. The ileosigmoid knot (also known as compound volvulus) is a rare cause of intestinal obstruction . The condition is initiated by loops of ileum wrapping around. he ileosigmoid knot (also known as compound volvulus) is a rare cause of intestinal obstruction . The condition is initiated by loops of ileum wrapping.
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The ileosigmoid knot is an uncommon but life-threatening cause of closed loop intestinal obstruction. Its treatment is different from a ipeosigmoid volvulus in that it has to be operated upon immediately.
Preoperative CT scan diagnosis knlt 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 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 knot also known as compound volvulus is an unusual and rare cause of intestinal obstruction.
The condition progresses rapidly to gangrene, so early diagnosis and operative treatment are vital. CT scan plays a major role in the evaluation of any acute abdomen.
Ileosibmoid year-old woman presented with a 3-day history of progressive abdominal pain associated with one episode of vomiting. She had no other concurrent disease and no significant past medical or surgical history. On examination, there was mild tenderness in the periumbilical and right lumbar region. Routine investigations were normal apart from leukocytosis total count: USG revealed dilated fluid-filled small bowel loops and free fluid in pelvis. A peritoneal tap revealed the fluid to be hemorrhagic.
Abdominal radiograph reveals a large gas-filled loop of the bowel in the right mid and lower quadrants. Stretched superior mesenteric vessels converged toward the whirl. In view of the history and the CT scan findings, a diagnosis of ileosigmoid knot with gangrene of the involved sigmoid colon and ileal loops was made. Axial CT scan of the abdomen A shows a dilated loop of the sigmoid ileoigmoid with a thinned-out wall thin arrow.
There is medial deviation of the cecum with a pointed medial border thick arrow.
Ileosigmoid knot: a case report and literature review of 280 cases
Notice the normal intervening ascending colon dotted arrow. B Caudal CT scan section shows the whirl sign within the circle created by the twisted mesentery and bowel branches arising from the superior mesenteric artery are present in the whirl.
There is medial deviation of the distal descending colon with a pointed medial border thick arrow. Fluid-filled ileal loops with thin non-enhancing walls are seen dotted arrow. C A more caudal CT scan section shows efferent limbs of the sigmoid colon thick arrow and the ileal loop dotted arrow with appearances khot a beak.
The whirl sign is present on this section as well thin arrow. A further caudal CT scan D shows fluid-filled ileal loops in the pelvis with thin non-enhancing ileoosigmoid solid arrow and free fluid present in the pelvic cavity dotted arrow.
The ileosigjoid was immediately operated. The gangrenous loops were resected and ileo-ascending colon and colo-colic anastomoses were done, along with a proximal defunctioning ileostomy.
The postoperative course was uneventful and the patient was discharged a week after the surgery. Subsequent follow-up was uneventful. Intraoperative photographs show a distended sigmoid colon solid arrow and gangrenous ileal loops dashed arrow wrapped around each other forming an ileosigmoid knot.
Diagrammatic illustration of the ileosigmoid knot. The long arrow points to the knot while the short arrows point to the medial displacement of the descending colon and cecum. Overall a rare entity, ileosigmoid knot is more common in Asia, Africa and the Middle East than in the West. In type I the commonestthe ileum is the active component, wrapping itself around the sigmoid colon passive component ileosig,oid form the knot, while in type II, it is ileosimgoid other way round.
In type III, the ileocecal segment acts as the active component, while in type IV undetermined type it is not ileosigoid to differentiate the two components from each other. Types I and II can be classified into subtypes A and B depending on whether the torsion is clockwise or counterclockwise, respectively. Although the mechanism by which an ileosigmoid knot develops is still speculative, it is generally accepted that certain anatomical predisposing factors are present, including a hypermobile small intestine with an elongated mesentery and a redundant sigmoid colon with ileosibmoid long mesocolon and a short attachment at the base of the mesentery.
Preoperative diagnosis of ileosigmoid knot is only infrequently made.
Ileosigmoid knot – Wikipedia
More often, the picture is that of either simple sigmoid volvulus or small bowel obstruction. CT scan reveals the classic whirl sign of volvulus created by the involved, twisted loops of the intestine and the mesocolon. Concurrent ischemic changes in the ileal loops and sigmoid colon should alert the radiologist. 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.
This is presumed to be due to the traction effect causing the peritoneum of the left paracolic gutter to move toward the center of the knot and the mass effect of the distended ileal loops interposing between the descending and proximal sigmoid colon and the left body wall. Stretched and elongated superior mesenteric along with inferior mesenteric vascular structures converging toward the sigmoid colon also indicate the diagnosis. At surgery, a prolonged attempt to untwist the knot is not recommended, especially if the bowel has become gangrenous.
Resection with primary anastomosis is advisable. Prompt treatment is mandatory. In conclusion, the ileosigmoid knot is a rare but life-threatening cause of closed-loop intestinal obstruction. Findings of simultaneous ileal and sigmoid ischemia with nonischemic colon interposed in between should prompt suspicion of this diagnosis. The presence of the whirl sign on CT scan — medially deviated distal descending colon and cecum, with mesenteric vascular structures from the superior mesenteric vessels converging toward the sigmoid colon — can help clinch the diagnosis.
National Center for Biotechnology InformationU. Indian J Radiol Imaging. Author information Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.
This article has been cited by other articles in PMC. Abstract The ileosigmoid knot is an uncommon but life-threatening cause of closed loop intestinal obstruction.
Compound volvulus, ileosigmoid knot, intestinal obstruction. Introduction Ileosigmoid knot also known as compound volvulus is an unusual and rare cause of intestinal obstruction. Case Report A year-old woman presented with a 3-day history of progressive abdominal pain associated with one episode of vomiting. Open in a separate window.
Figure 3 Ileodigmoid, B. Discussion Overall a rare entity, ileosigmoid knot is more common in Asia, Africa and the Middle East than in the West. Footnotes Source of Support: Nil, Conflict of Interest: Ileosigmoid knotting in Turkey. Review of 68 cases. Impact of CT on diagnosis and management of acute abdomen in patients initially treated without surgery.