An ileosigmoid knot or compound volvulus is an uncommon cause of

intestinal blockage Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs ...

. The condition arises when

ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine may ...

loops wrap around the bottom of a redundant

sigmoid Sigmoid means resembling the lower-case Greek letter sigma (uppercase Σ, lowercase σ, lowercase in word-final position ς) or the Latin letter S. Specific uses include: * Sigmoid function, a mathematical function * Sigmoid colon, part of the l ...

loop. In some countries in Africa, Asia, and the Middle East, the ileosigmoid knot is a well-known ailment; this condition is uncommon in the West.

Signs and symptoms

Ileosigmoid knotting typically manifests as sudden, severe

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

. It can quickly worsen into

sigmoid colon The sigmoid colon (or pelvic colon) is the part of the large intestine that is closest to the rectum and anus. It forms a loop that averages about in length. The loop is typically shaped like a Greek letter sigma (ς) or Latin letter S (thus ''s ...

and

gangrene, which can lead to potentially fatal side effects like

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

, generalized

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

electrolyte imbalance Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function ...

, and

dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...

Abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

and tenderness (100%) and distension of the abdomen (94%–100%),

vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...

and

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

(87–100%), rebound tenderness (69%), as well as

shock Shock may refer to: Common uses Healthcare * Acute stress reaction, also known as psychological or mental shock ** Shell shock, soldiers' reaction to battle trauma * Circulatory shock, a medical emergency ** Cardiogenic shock, resulting from ...

(0–60%) are the main symptoms and presentation indicators.

Causes

The ileosigmoid knot is caused by three things: eating a high-bulk diet while the

small bowel The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the p ...

is empty; having a long,

on a tiny pedicle; and having a long, mesentery, and freely moving

. The intestines become more mobile when a semi-liquid, heavy meal moves into the proximal

jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialized for the absorption by enterocytes of small nutrient molecules which have been pr ...

, and the heavier sections of the

fall to the left lower quadrant. Around the base of the narrow

, the empty loops of the

and distal

rotate in a clockwise direction. With two closed-loop obstructions—one in the small bowel and the other in the

—further

peristalsis Peristalsis ( , ) is a type of intestinal motility, characterized by symmetry in biology#Radial symmetry, radially symmetrical contraction and relaxation of muscles that propagate in a wave down a tube, in an wikt:anterograde, anterograde dir ...

creates an ileosigmoid knot.

Diagnosis

Even though radiographic findings indicate colonic obstruction, which is uncommon in small bowel obstruction, clinical features like

point to

small bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

. Ileosigmoid knotting is frequently confused radiographically with a straightforward sigmoid volvulus. On the other hand, in contrast to sigmoid volvulus, attempts to deflate the enlarged colon with a flatus tube or

sigmoidoscope Sigmoidoscopy ("sigma", the Greek term for letter " s/ς" + "eidos" + "scopy": namely, to look inside an "s"/"ς"-like object) is the minimally invasive medical examination of the large intestine from the rectum through to the nearest part of the ...

frequently fail and may even be hazardous in ileosigmoid knotting. This is because the ileum firmly encloses the sigmoid colon's base, thwarting any such attempt. These three characteristics—the inability to insert a

, radiographic evidence of primarily large bowel obstruction, and the clinical picture of small

bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

—might make up a helpful diagnostic triad. Due to their unfamiliarity, the radiographic findings of ileosigmoid knotting—which include multiple air-fluid levels in the small intestine and a double loop of dilated sigmoid shadow—are only occasionally described. The descending colon, medial deviation of the cecum, and "the whirl sign," which is produced by the twisted

intestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. ...

and sigmoid mesocolon in ileosigmoid knot, are findings in a

CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

that are suggestive of ileosigmoid knotting. Furthermore, some have observed the radial distribution of the mesenteric vasculature and the intestine and believe this to be useful diagnostic data.

Classification

Ileosigmoid knotting has been classified into the three types listed below: Type 1: The

, which is the active component, encircles the

, which is the passive component, either clockwise or counterclockwise (type A when clockwise and type B when counterclockwise). Type 2: In either a clockwise or counterclockwise direction, the

, the active component, encircles an

loop, the passive component. Type 3: The

(passive component) is encircled by the ileocecal segment (active component).

Treatment

Aggressive resuscitation with fluid and

electrolytes An electrolyte is a substance that conducts electricity through the movement of ions, but not through the movement of electrons. This includes most soluble salts, acids, and bases, dissolved in a polar solvent like water. Upon dissolving, t ...

, along with the correction of any acid-base imbalance, are the initial management measures. The earliest possible surgical intervention should be performed following hemodynamic stabilization. After the procedure, appropriate

antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...

therapy is started as soon as possible and is continued for 5-7 days.

Metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...

aminoglycosides Aminoglycoside is a medicinal chemistry, medicinal and bacteriology, bacteriologic category of traditional Gram-negative antibacterial medications that inhibit protein synthesis and contain as a portion of the molecule an amino-modified glycoside ...

, and

cephalosporins The cephalosporins (sg. ) are a class of β-lactam antibiotics originally derived from the fungus ''Acremonium'', which was previously known as ''Cephalosporium''. Together with cephamycins, they constitute a subgroup of β-lactam antibiotic ...

are the typical

combinations.

Epidemiology

Males account for 80.2% of cases of ileosigmoid knotting, with a mean age of 40 years (range: 4-90 years). The literature indicates the presence of additional secondary causative factors in addition to the aforementioned anatomic prerequisites, such as late pregnancy, Meckel's diverticulitis with a band, trans mesenteric

herniation A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the in ...

, floating

cecum The cecum ( caecum, ; plural ceca or caeca, ) is a pouch within the peritoneum that is considered to be the beginning of the large intestine. It is typically located on the right side of the body (the same side of the body as the appendix (a ...

, and ileocecal intussusceptions. Ileosigmoid knotting is uncommon in the white population, although it is primarily documented in some African, Asian, and Middle Eastern countries.

History

E Parker is credited with describing the first case of ileosigmoid knotting in 1846.

References

External links

{{Digestive system diseases Gastrointestinal tract disorders