Gangrenous appendico-ileal knotting causing strangulated small-bowel obstruction and shock in a patient with a virgin abdomen: a case report

Appendico-ileal knotting (AIK) is a rare cause of closed-loop small-bowel obstruction in which the appendix encircles the ileum or its mesentery, potentially causing rapid strangulation, ischemia, and gangrene. Because its presentation overlaps with more common causes of small-bowel obstruction, diagnosis is usually made during surgery. This case highlights the need for urgent operative assessment in patients with bowel obstruction, peritonitis, and hemodynamic instability, including those with a virgin abdomen. A 52-year-old Ethiopian man with no previous abdominal surgery presented after 2 days of generalized abdominal pain, distension, bilious vomiting, and obstipation. He was hypotensive, tachycardic, dehydrated, and had generalized peritonitis. Plain abdominal radiography showed features of small-bowel obstruction. Following resuscitation, antibiotics, and vasopressor support, emergency laparotomy was undertaken for suspected strangulated small-bowel obstruction. Approximately 2 L of hemorrhagic intraperitoneal fluid was encountered. A 16-cm inflamed appendix tightly encircled the distal ileum, forming an appendico-ileal knot with approximately 100 cm of gangrenous ileum. Appendectomy and ileal resection were performed. Because only a very short distal ileal stump remained adjacent to a viable ileocecal valve, the stump was closed and intestinal continuity was restored with an end-to-side ileo-transverse anastomosis. Shock resolved by postoperative day 2, and the patient remained well through postoperative day 30. AIK is a rare but potentially catastrophic cause of strangulated small-bowel obstruction. In patients with features of peritonitis, shock, or bowel ischemia, prompt resuscitation and surgical exploration are essential. Intraoperative assessment of bowel viability and a tension-free, individualized reconstruction guide management.