Compound Volvulus: A Rare Case of Intestinal Obstruction

Compound volvulus or ileosigmoid knotting is an uncommon surgical emergency that causes intestinal obstruction. The sigmoid and ileum are mostly involved in this closed-loop intestinal obstruction. It is regarded as a rather uncommon cause of intestinal obstruction. It's important to distinguish between an ileosigmoid knot and a simple sigmoid volvulus since the management of the two is different. CT and MRI are more helpful in the diagnosis than abdominal X-ray findings, which are not pathognomonic. After resuscitation, a patient with ileosigmoid knotting typically needs an emergency laparotomy. Different resectional and non-resectional surgical procedures may be employed depending on the viability of the ileum and sigmoid colon.


Introduction
Ileosigmoid knotting (ISK) is a less-known cause of intestinal obstruction that results in a compound loop bowel obstruction by wrapping either the ileum or the sigmoid colon around the base of the other [1][2][3].Although the prevalence is unknown, it is frequently observed in regions of the world where sigmoid volvulus (SV) is prevalent.In Eastern and Western nations, it makes up for 18-50% and 5-8% of SV cases, respectively [2][3].With a high occurrence in the third to fifth decade, it is predominantly a male disease [3].
In 1845, Parker published the first ISK case [4].The second case was reported by Kallio in 1932.In 1940, Paul wrote about the first instance of ISK from the Asian subcontinent.A very few cases have been described in the literature so far.Only 0-28% of cases could be detected preoperatively, making this surgical disease a diagnostic dilemma.Large gas-filled small and large bowel loops can be seen in the right mid and lower abdomen on an X-ray of the abdomen.Dilated, fluid-filled intestinal loops and free fluid in the pelvis are shown on ultrasound.The best diagnostic technique for making the correct diagnosis is computed tomography (CT) [1][2][3][4].

Case Presentation
A 45-year-old gentleman presented in our surgical emergency with generalized abdominal pain for six days and non-passage of stool and flatus for five days.The patient had no history of trauma or past treatment/surgical history.
On examination, the patient was conscious with BP 81/55 mmHg and pulse 114/min.The abdomen was distended with generalized tenderness, guarding, and absent bowel sounds.A nasogastric tube was inserted for proximal decompression and urethral catheterisation was done.Per-rectal examination shows a dilated rectum with no fecal staining.An erect X-ray of the abdomen (Figure 1) revealed dilated small and larger bowel loops.Ultrasonography (USG) abdomen revealed moderate ascites with internal septations and dilated bowel loops.Contrast-enhanced computed tomography (CECT) abdomen done from outside the hospital (blurred images) shows moderate ascites with closed loop obstruction, distal ileum twisting (360) around the sigmoid colon, and its mesentery suggestive of compound volvulus.CECT report shows of multiple subcentimetric mesenteric nodes with fat stranding suggestive of mesenteric lymphadenopathy.

FIGURE 1: X-ray abdomen-dilated small and large bowel loops.
Arrow showing dilated bowel loops.
The patient was resuscitated with IV fluid therapy, broad-spectrum antibiotics, analgesics, and antiemetics.
The patient was admitted to the intensive care unit for further monitoring and stabilization.Later he was started on ionotropic support and planned for emergency exploratory laparotomy.The pre-operative patient was conscious and oriented (BP 92/66 mmHg, PR 111/min on inotropic support, SpO2 97% on oxygen support at 4 L/min).
Intraoperatively sigmoid colon was found gangrenous (Figure 2) and rotated 360 degrees anticlockwise along its axis.Distal ileum approximately one foot from ileocaecal junction (ICJ) was found entangled around the base of the sigmoid colon (Figure 3).The distal ileum, caecum, and proximal ascending colon were found gangrenous.Resection of the gangrenous bowel with double barrel ileocolostomy, Hartmann procedure and distal transverse colon mucus fistula on the left side (Figure 4) was done in view of hemodynamic instability.A transverse colon mucus fistula was created to assess the bowel viability as the patient was on ionotropic support.The patient was taken for stoma reversal after 16 weeks after an adequate gain in body weight.A preoperative distal loopogram (Figure 5) was done which revealed normal bowel loops without any contrast extravasation from the rectal stump.Using a midline approach ileocolic and colorectal anastomosis was done by 75 mm G.I. stapler and circular stapler respectively.The patient was discharged after eight days of hospital stay without any significant post-operative complications.

Discussion
The ISK is a type of closed-loop intestinal obstruction that is uncommon but potentially fatal.ISK's exact mechanism is currently unknown [5,6].Predisposing anatomical variables include a large small bowel mesentery and a narrow sigmoid pedicle.The illness mostly affects adults in their thirties and forties, with a mean age of 35.8 to 55. ISK is primarily a male condition for unknown causes, similar to primary small bowel volvulus and sigmoid volvulus.Usually, patients with ISK present significantly earlier.However, delayed presentation is not unusual.According to the literature, the average symptom duration at presentation ranged from 0.9 to 4.4 days [7][8][9].Abdominal pain or tenderness, vomiting, inability to pass flatus or feces, abdominal distention, a hypoactive bowel sounds are the main symptoms of ISK upon presentation.Up to 60% of patients with ISK present with shock [8][9].In a patient with clinical indications of bowel obstruction, the presence of features of double intestinal obstruction and dilated large and small bowel loops with multiple air-fluid levels should be a strong diagnostic of the potential diagnosis of ISK.Strangulation rates in the literature range from 73.5 to 93.9% and both segments are frequently affected (the ileum and sigmoid) [9].
Four types of ileosigmoid knotting are summarized in Table 1.In the present case, we have a type 2B knot with 360° of sigmoid over ileocecum.A new classification of ileosigmoid knotting is described in Table 2.
When a patient presents with similar complaints, management should start with urgent intravenous fluid resuscitation and stabilization.Due to the high prevalence of bowel gangrene and concomitant bacterial translocation, empiric antibiotic therapy should be started as soon as possible and continued following surgery, especially in gangrenous bowel [10][11].The presence of shock, surgical morbidity and laparotomy findings should all be taken into consideration for choice of procedure [12].A definitive procedure may be performed during the initial laparotomy in patients who remain hemodynamically stable during the surgery.
If the portion of the small bowel implicated in the knot is extensive and of doubtful viability with a risk of   ISK is an uncommon entity with a poor prognosis.For each of these cases, a high level of suspicion is necessary.An immediate exploratory laparotomy is the best option for a better outcome in consideration of the diagnostic ambiguity and the fatal course of the disease.

Conclusions
ISK is a less-known cause of intestinal obstruction that is frequently associated with bowel gangrene and high mortality.In order to effectively treat this condition, an emergency laparotomy along with a good preand post-operative care is required.Most cases of compound volvulus can be safely treated with damage control surgery.
was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

FIGURE 3 :
FIGURE 3: Preoperative distal loopogram with contrast inserted through transverse loop colostomy (Image A) and rectal contrast (Image B)Image A -colostomy, no dye leak.Image B -rectum with no dye leak.

FIGURE 4 :
FIGURE 4: Laparotomy showing twisting of ileum and sigmoid colon with gangrenous changes.Blue arrow -sigmoid loop.White arrow -ileal loops.Black arrow -Axis of knotting.

FIGURE 5 :
FIGURE 5: The patient at 14 weeks of surgery.End ileostomy (blue arrow), transverse colon mucus fistula (white arrow) on the right side with descending colon mucus fistula (black arrow) on the left side.