Appendico-ileal knotting a rare cause of small bowel obstruction; case report and literature review from Leku general hospital,Ethiopia

Appendico-ileal knotting a rare cause of small bowel obstruction; case report and literature review from Leku general hospital,Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Appendico-ileal knotting a rare cause of small bowel obstruction; case report and literature review from Leku general hospital,Ethiopia Asfaw Kibret Tefera, Muluken Asres, Thomas Ameno This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7860119/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Small bowel obstruction is the common caus of acute abdomen for which emergency surgical intervention is mandatory. Bowel knottings like ileosigmoid knotting, ileoileal knotting,ileocecal knotting and appendicoileal knottings are rare ocurrances as a cause of obstruction.Among these appendicoileal knotting is by far the rarest cause of obstruction. Since its 1st report in 1901, there are case reports of this scenario but all associated it with the presence of appendicitis. We report a 28yrs old female patient who presented with sign symptom of small bowel obstruction for whom appendico-ileal knotting is identified with healthy looking appendix rapped around the distal ileum which was a near miss bowel segment which later returned healthy after the appendix release and warm saline socked sterile pack rapped for a minutes.Appendicoileal knotting can occur in the absence of preceding appendicitis. General Surgery bowel obstruction appendicitis appendicoileal knotting double loop obstruction intraoperative surprise Figures Figure 1 Introduction Bowel obstruction in general is common cause for acute abdomen which most of the time needs emergency surgical intervension.Small bowel obstruction is the commonest cause worldwide. There are a lot of causes of small bowel obstruction( 1 , 2 ). Post-operative adhesion,hernia and malignancies are the most commonest causes to mention worldwide.But small bowel volvulus is the commonest in most part of our country Ethiopia.Bowel knotting like,ileosigmoid,ileoileal,ileocecal and appendicoileal are rare causes of bowel obstruction( 12 ).Among these appendicoileal knotting is the rarest to be occurred in bowel obstruction( 3 , 4 ).Since 1901 of the 1st documented report there are few handful of cases reported in literatures( 13 ).Appendicoileal knotting is rapping of the appendex over the segment of distal ileum which causes closed loop obstruction.If untreated or delayed,it results in bowel vascular compromise and eventual bowel ischemia.Preoperative diagnosis is challenging since it has no pathognomonic features but mimic other intestinal obstruction causes of clinical presentations.Preoperative imaging,including computed tomography(CT),has shown potential utility ,but its accuracy is limited and in resource limited setups its accessibility is ambitious.( 6 , 7 ) This case report adds another literature asset to the existing handful of cases world-wide with some peculiarities of uninflammed appendex causing appendico-ileal knotting in 28yrs old female patient. Case presentation This is a 28yrs old female patient who presented to emergency room with the complain of abdominal pain of 3days duration.She complained that she has crampy abdominal pain which started at the periumblical area.In associated to this she had repeated episode of bilious type of vomiting,failure to pass fecess and flatus.For this complain she had been taken to her nearby private clinic and analgesics were given.But inspite of this her complain worsened and abdominal distension also started.She has no previous medical and surgical histories.She has 3 children and currently she is using family planning method.She had no vaginal bleeding ,no vaginal discharge and no history of trauma. Upon presentation she was acute sick looking with BP = 90/60mmgh,PR = 112Bpm of tachycardia,RR = 21Breath/min,T = 36.9,PSO2 = 96% off oxygen.On physical examination there was dry bucal mucosa,dry tongue and on abdominal examination there was abdominal distension with hypertympanicity on percussion,there was also minimal tenderness upon palpation .Digital rectal examination revealed empty rectum.Labratory investigation came with CBC = 16,000,Hgb = 12g/dl,PLT = 250000,RBS = 150,Imaging suggested with multiple air fluid levels with preoperative diagnosis of SBO secondary to small bowel volvulus.For this diagnosis patient prepared for exploratory laparotomy.Medline abdominal incision used to open the abdominal cavity.Upon entery to the abdominal cavity there was moderately hemorrhagic free peritoneal fluid comes out and there was multiple small bowel loops distended,near to ischemia,especially the distal ileal segment.Surprisingly the was long non inflamed appendex rapped around the distal segment of the ileum near to the ileocecal junction,the tip of the appendex was buried to to the ileal mesentery otherwise it was intact and no fecolith in it(Fig. 1 ).Then the appendex released from around the entrapped distal ileal segment which was in double segment obstruction.Then after appendectomy done,the discoloured ileal segment rapped by warm saline soaked sterile surgical pack and time taken.Later the peristalysis and colour of the enterapped bowel segment returned normal.After meticulous observation of all segment of the small bowel, colon and other solid organ,no pathology witnessed then abdomen closed in layer and patient awaken and left OT stable. Her post operation course was uneventful, she discharged home on the 4rth day and came 2weeks later for follow in stable condition. Discussion Appendico-ileal knotting remains an exceedingly rare cause of small bowel obstruction (SBO), often presenting a significant diagnostic challenge. As evidenced by the collected case reports, the condition lacks a pathognomonic clinical presentation, with symptoms typically overlapping with other, more common, causes of SBO, such as volvulus, adhesions or hernias. This leads to most diagnoses being made intra-operatively, often as a "surprise" finding during exploratory laparotomy. ( 15 , 16 ) *Summarized tables of few case reports of appendicoileal knotting. Author and year age sex Clinical presentatio Intraoperative findings procedure outcome Mandal et al(2025) 64 male Abdominal pain, vomiting, inability to pass stool and flatus. Appendix mucocele knotting causing cecal and ileal gangrene Limited right hemicolectomy and double-barrel stoma. Uneventful postoperative recover Abule T,Chebo T,Billoro BB,2022 30 Female Colicky abdominal pain, vomiting, and constipation Appendico-ileal knot causing small bowel obstruction (SBO). Untwisting of the knot, appendectomy Uneventful recovery, discharged on day 4. Idowu NA et al.,2024 72 Male Colicky abdominal pain, nausea, vomiting, constipation, and fever over 4 days. Appendico-ileal knotting with gangrenous appendix and terminal ileum. Limited right hemicolectomy and ileo-colonic anastomosis. Discharged on postoperative day 10. Kifle T et al 2018 46 female Acute abdomen with severe pain, bilious vomiting, and constipation for 7 days. Confirmed appendiceal knotting with apperndicular mucocele causing SBO. Laparotomy with untwisting of the knot, followed by appendectomy. Recovered well.and discharged on the 5th post op date Kabuye U et al.,2024 28 female Abdominal pain, vomiting, and constipation. Initial diagnosis was SBO from an intestinal band. Appendix entangled around the terminal ileum, causing a closed-loop obstruction. The appendix was gangrenous, but the ileum was viable. Retrograde appendectomy after releasing the knot. Uneventful recovery, discharged on day 4. Zewdu D et al.,2022 34 male SBO symptoms Ileoappendicular knotting Appendectomy,with resection of gangrenous bowel Full recovery, though experienced post-op diarrhea. Kassahun B et al., 2025 28 male Progressive lower abdominal pain, nausea, anorexia, and bilious vomiting for 2 days. Gangrenous 20 cm appendix tightly encircling 1 m of gangrenous distal ileum. Untwisting of the knot, appendectomy, resection of the gangrenous ileum, and end-to-side ileo-transverse anastomosis. Uneventful recovery, discharged on postoperative day 6. Klein et al.2024 80 Female Small bowel obstruction sign and symptom of 1 day duration Appendicular knot of healthy appendex,obstructing the small bowel as closed loop obstruction appendectomy Discharged well Alemu et al 50 Female Abdominal pain, vomiting, abdominal distension. Appendicoileal knotting with gangrenous ileum and appendix mucocele Bowel and appendix resection with ileotransverse anastomosis Discharged on the 7th post operative date Lin, Tso-Lin et al 2017 4 male Vomiting,abdominal pain Inflamed appendex causing appendiculoileal band knot appendectomy Discharged uneventfully The patient demographic in these cases varies widely, spanning from pediatric patients to the elderly. The specific pathophysiology depends on an elongated, mobile appendix, which can become inflamed and form a constricting band around a loop of the ileum. The outcome is critically dependent on the timing of surgical intervention. Early intervention, as seen in cases where the bowel remains viable, allows for a straightforward procedure involving the untwisting of the knot and appendectomy. In contrast, delayed presentation or diagnosis, especially in resource-limited settings, can lead to catastrophic complications such as bowel gangrene, perforation, and septic shock, requiring more extensive and complex procedures, such as bowel resection and anastomosis.( 1 – 10 ) Histopathological findings, when available, sometimes reveal an associated mucocele of the appendix, as noted in the cases by Mandal et al. (2025) B and Alemu et al.(2023).( 1 , 9 ).This finding suggests that certain appendiceal pathologies might contribute to the knotting mechanism. In most cases appendicitis was mentioned as a preceding incident to appendicoileal knotting. Yet,only Klein et al(2024) reported the occurrence of appendico-ileal knotting in the presence of macroscopically and microscopically healthy looking appendex( 8 ).Our case also presented with the same finding with Klein et al(2024) report. So appendix can be a cause for small bowel obstruction in the presence of its inflammation or only mechanically as a band in the absence of its inflammation. There are two basic situations where the appendix may also cause a mechanical obstruction appendicular tip attached to the mesentery surrounding an ileal loop, producing compression of its lumen and the appendicular tip attached to the intestinal serosa, producing the obstruction by direct compression or torsion of a loop. The overall literature emphasizes that while appendico-ileal knotting is a rare event, a high index of clinical suspicion is necessary in patients presenting with SBO, especially in the absence of a clear etiology like a history of prior surgery. Early diagnosis and prompt surgical management are the cornerstones of successful treatment and significantly improve patient outcomes. But the overall management depends on the viability of the bowel or strangulation.( 11 , 14 , 15 ) Conclusion Appendico ileal knotting is still rare cause for small bowel obstruction.But as abdomen is “a Pandora box” the very rare things can happen and clinical suspicion is needed. Early diagnosis may help the patient for early surgical intervention.Appendico ileal knotting can occur in the absence of appendicitis. Declarations Acknowledgement: We would like to thank all leku general hospital clinical staffs who are involved in the management of the patient specially to the operating theater nurses andansthetists. Fund :no fund for this case report Informed Consent: Written informed consent was obtained from the patient for publi cation of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Ethical approval :N/A Conflict of Interest :no conflict of interest. Data Availability :All relevant data are within the paper and its Supporting Information files References Mandal, M. K., Sarkar, N., Sarkar, S., & Mollah, J. (2025). A case of appendiculo-ileal knotting as a cause of gangrenous small bowel obstruction in a 64-year-old man in a Government Hospital, West Bengal, India. International Surgery Journal , 12 (8), 1383–1386. https://doi.org/10.18203/2349-2902.isj20252295 Abule T, Chebo T, Billoro BB. Appendico-ileal knotting causing small bowel obstruction: A case report. Clin Case Rep. 2022 May 15;10(5):e05878. doi: 10.1002/ccr3.5878. PMID: 35600040; PMCID: PMC9107922 Najeem Adedamola IDOWU, Waheed Olalekan ISMAEEL, Akeem Aderogba ADELEKE, Joshua Adejare FALEYE, Suliyat Adebisi ADELEYE-IDOWU, & Kehinde Aderonke ADEMOYE. (2024). Appendico-Ileal Knotting: A Rare Cause of Strangulated Small Bowel Obstruction. Ethiopian Journal of Health Sciences , 34 (2). https://doi.org/10.4314/ejhs.v34i2.7 Kifle Anteneh Tadesse, Tesfaye Samuel. Appendico ilial knotting: a rare cause of small bowel obstruction. J. Surg. Case Rep. May 2018;2018(5) doi: 10.1093/jscr/rjy088. [DOI] [PMC free article] [PubMed] [Google Scholar U. Kabuye, J. Damulira, M.D. Okuku Appendico-ileal knot: a rare form of small bowel obstruction:a case report Int.J.Surg. Case Rep., 123 (2024), Article 110194, 10.1016/j.ijscr.2024.110194 Wondwosen M, Tantu T, Zewdu D. Appendiceal knotting causing small bowel obstruction: A rare case report. International Journal of Surgery Case Reports. 2022 Apr;93:106970. DOI: 10.1016/j.ijscr.2022.106970. PMID: 35367944; PMCID: PMC8980631. Berhanu Kassahun, Abebe Dilie Afenigus, Gangrenous small bowel obstruction resulting from appendico-ileal knotting: a rare case report from Bete Markos Medical and Surgical Center, Ethiopia, Journal of Surgical Case Reports , Volume 2025, Issue 7, July 2025, rjaf539, https://doi.org/10.1093/jscr/rjaf539 Klein Nulend R, Quinn R, Fok KY, Pathmanathan N. The appendix: An unexpected band obstruction. J Case Rep Article ID: 100129Z12RN2024 Alemu DS, Arefayne M, Bekele T, Sahle G, Getachew A. A Case of Appendiculo-Ileal Knotting As a Cause of Gangrenous Small Bowel Obstruction in a 50-Yr-Old-Woman, in a Private Hospital. J Surg Surgic Case Rep. 2023;4(2):1036 Intestinal obstruction caused by appendiceal knot Lin, Tso-Lin et al.Pediatrics & Neonatology, Volume 60, Issue 2, 216 - 217 Bhandari L., Mohandas P. Appendicitis as a cause of intestinal strangulation: a case report and review. World J. Emerg. Surg. 2009;4:34. doi: 10.1186/1749-7922-4-34. [DOI] [PMC free article] [PubMed] [Google Scholar] Kibret A. Ileo-Ileal Knotting a Rare Cause of Double Loop Small Bowel Obstruction, Diagnostic and Intraoperative Challenge at Ethiopian Leku District Hospital, Sidama Region, April 2023: Case Report. Clin Surg. 2023; 8: 3657. Hotchkiss LW. Acute intestinal obstructionfollowing appendicitis: A report of three casessuccessfully operated upon. Ann Surg.1901;34:660–77 Nulend RK, Quinn R, Fok KY, Pathmanathan N. The Appendix: An Unexpected Band Obstruction. Journal of Case Reports and Images in Surgery. 2024;10(1):1-9. JG M, SA K, LJ A, EA A. Intestinal obstruction caused by appendicitis: a systematic review. Journal of the West African College of Surgeons. 2017 Jul;7(3):94. Awale L, Joshi BR, Rajbanshi S, Adhikary S. Appendiceal tie syndrome: A very rare complication of a common disease. World J SGastrointest Surg 2015;7(4):67–70. Additional Declarations The authors declare no competing interests. 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There are a lot of causes of small bowel obstruction(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Post-operative adhesion,hernia and malignancies are the most commonest causes to mention worldwide.But small bowel volvulus is the commonest in most part of our country Ethiopia.Bowel knotting like,ileosigmoid,ileoileal,ileocecal and appendicoileal are rare causes of bowel obstruction(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).Among these appendicoileal knotting is the rarest to be occurred in bowel obstruction(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).Since 1901 of the 1st documented report there are few handful of cases reported in literatures(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).Appendicoileal knotting is rapping of the appendex over the segment of distal ileum which causes closed loop obstruction.If untreated or delayed,it results in bowel vascular compromise and eventual bowel ischemia.Preoperative diagnosis is challenging since it has no pathognomonic features but mimic other intestinal obstruction causes of clinical presentations.Preoperative imaging,including computed tomography(CT),has shown potential utility ,but its accuracy is limited and in resource limited setups its accessibility is ambitious.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis case report adds another literature asset to the existing handful of cases world-wide with some peculiarities of uninflammed appendex causing appendico-ileal knotting in 28yrs old female patient.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThis is a 28yrs old female patient who presented to emergency room with the complain of abdominal pain of 3days duration.She complained that she has crampy abdominal pain which started at the periumblical area.In associated to this she had repeated episode of bilious type of vomiting,failure to pass fecess and flatus.For this complain she had been taken to her nearby private clinic and analgesics were given.But inspite of this her complain worsened and abdominal distension also started.She has no previous medical and surgical histories.She has 3 children and currently she is using family planning method.She had no vaginal bleeding ,no vaginal discharge and no history of trauma.\u003c/p\u003e\u003cp\u003eUpon presentation she was acute sick looking with BP\u0026thinsp;=\u0026thinsp;90/60mmgh,PR\u0026thinsp;=\u0026thinsp;112Bpm of tachycardia,RR\u0026thinsp;=\u0026thinsp;21Breath/min,T\u0026thinsp;=\u0026thinsp;36.9,PSO2\u0026thinsp;=\u0026thinsp;96% off oxygen.On physical examination there was dry bucal mucosa,dry tongue and on abdominal examination there was abdominal distension with hypertympanicity on percussion,there was also minimal tenderness upon palpation .Digital rectal examination revealed empty rectum.Labratory investigation came with CBC\u0026thinsp;=\u0026thinsp;16,000,Hgb\u0026thinsp;=\u0026thinsp;12g/dl,PLT\u0026thinsp;=\u0026thinsp;250000,RBS\u0026thinsp;=\u0026thinsp;150,Imaging suggested with multiple air fluid levels with preoperative diagnosis of SBO secondary to small bowel volvulus.For this diagnosis patient prepared for exploratory laparotomy.Medline abdominal incision used to open the abdominal cavity.Upon entery to the abdominal cavity there was moderately hemorrhagic free peritoneal fluid comes out and there was multiple small bowel loops distended,near to ischemia,especially the distal ileal segment.Surprisingly the was long non inflamed appendex rapped around the distal segment of the ileum near to the ileocecal junction,the tip of the appendex was buried to to the ileal mesentery otherwise it was intact and no fecolith in it(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).Then the appendex released from around the entrapped distal ileal segment which was in double segment obstruction.Then after appendectomy done,the discoloured ileal segment rapped by warm saline soaked sterile surgical pack and time taken.Later the peristalysis and colour of the enterapped bowel segment returned normal.After meticulous observation of all segment of the small bowel, colon and other solid organ,no pathology witnessed then abdomen closed in layer and patient awaken and left OT stable. Her post operation course was uneventful, she discharged home on the 4rth day and came 2weeks later for follow in stable condition.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAppendico-ileal knotting remains an exceedingly rare cause of small bowel obstruction (SBO), often presenting a significant diagnostic challenge. As evidenced by the collected case reports, the condition lacks a pathognomonic clinical presentation, with symptoms typically overlapping with other, more common, causes of SBO, such as volvulus, adhesions or hernias. This leads to most diagnoses being made intra-operatively, often as a \"surprise\" finding during exploratory laparotomy. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e*Summarized tables of few case reports of appendicoileal knotting.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor and year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003esex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClinical presentatio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIntraoperative findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eprocedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eoutcome\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMandal et al(2025)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbdominal pain, vomiting, inability to pass stool and flatus.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendix mucocele knotting causing cecal and ileal gangrene\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLimited right hemicolectomy and double-barrel stoma.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUneventful postoperative recover\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbule T,Chebo T,Billoro BB,2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eColicky abdominal pain, vomiting, and constipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendico-ileal knot causing small bowel obstruction (SBO).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUntwisting of the knot, appendectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUneventful recovery, discharged on day 4.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdowu NA et al.,2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eColicky abdominal pain, nausea, vomiting, constipation, and fever over 4 days.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendico-ileal knotting with gangrenous appendix and terminal ileum.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLimited right hemicolectomy and ileo-colonic anastomosis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDischarged on postoperative day 10.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKifle T et al 2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAcute abdomen with severe pain, bilious vomiting, and constipation for 7 days.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConfirmed appendiceal knotting with apperndicular mucocele causing SBO.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLaparotomy with untwisting of the knot, followed by appendectomy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRecovered well.and discharged on the 5th post op date\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKabuye U et al.,2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbdominal pain, vomiting, and constipation. Initial diagnosis was SBO from an intestinal band.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendix entangled around the terminal ileum, causing a closed-loop obstruction. The appendix was gangrenous, but the ileum was viable.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRetrograde appendectomy after releasing the knot.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUneventful recovery, discharged on day 4.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eZewdu D et al.,2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSBO symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIleoappendicular knotting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAppendectomy,with resection of gangrenous bowel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFull recovery, though experienced post-op diarrhea.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKassahun B et al., 2025\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProgressive lower abdominal pain, nausea, anorexia, and bilious vomiting for 2 days.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGangrenous 20 cm appendix tightly encircling 1 m of gangrenous distal ileum.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUntwisting of the knot, appendectomy, resection of the gangrenous ileum, and end-to-side ileo-transverse anastomosis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUneventful recovery, discharged on postoperative day 6.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKlein et al.2024\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSmall bowel obstruction sign and symptom of 1 day duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendicular knot of healthy appendex,obstructing the small bowel as closed loop obstruction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eappendectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDischarged well\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAlemu et al\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbdominal pain, vomiting, abdominal distension.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAppendicoileal knotting with gangrenous ileum and appendix mucocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBowel and appendix resection with ileotransverse anastomosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDischarged on the 7th post operative date\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLin, Tso-Lin et al 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVomiting,abdominal pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInflamed appendex causing appendiculoileal band knot\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eappendectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDischarged uneventfully\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient demographic in these cases varies widely, spanning from pediatric patients to the elderly. The specific pathophysiology depends on an elongated, mobile appendix, which can become inflamed and form a constricting band around a loop of the ileum. The outcome is critically dependent on the timing of surgical intervention. Early intervention, as seen in cases where the bowel remains viable, allows for a straightforward procedure involving the untwisting of the knot and appendectomy. In contrast, delayed presentation or diagnosis, especially in resource-limited settings, can lead to catastrophic complications such as bowel gangrene, perforation, and septic shock, requiring more extensive and complex procedures, such as bowel resection and anastomosis.(\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eHistopathological findings, when available, sometimes reveal an associated mucocele of the appendix, as noted in the cases by Mandal et al. (2025) B and Alemu et al.(2023).(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).This finding suggests that certain appendiceal pathologies might contribute to the knotting mechanism. In most cases appendicitis was mentioned as a preceding incident to appendicoileal knotting. Yet,only Klein et al(2024) reported the occurrence of appendico-ileal knotting in the presence of macroscopically and microscopically healthy looking appendex(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).Our case also presented with the same finding with Klein et al(2024) report. So appendix can be a cause for small bowel obstruction in the presence of its inflammation or only mechanically as a band in the absence of its inflammation. There are two basic situations where the appendix may also cause a mechanical obstruction appendicular tip attached to the mesentery surrounding an ileal loop, producing compression of its lumen and the appendicular tip attached to the intestinal serosa, producing the obstruction by direct compression or torsion of a loop. The overall literature emphasizes that while appendico-ileal knotting is a rare event, a high index of clinical suspicion is necessary in patients presenting with SBO, especially in the absence of a clear etiology like a history of prior surgery. Early diagnosis and prompt surgical management are the cornerstones of successful treatment and significantly improve patient outcomes. But the overall management depends on the viability of the bowel or strangulation.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAppendico ileal knotting is still rare cause for small bowel obstruction.But as abdomen is “a Pandora box” the very rare things can happen and clinical suspicion is needed. Early diagnosis may help the patient for early surgical intervention.Appendico ileal knotting can occur in the absence of appendicitis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e\u003cem\u003eWe would like to thank all leku general hospital clinical staffs who are involved in the management of the patient specially to the operating theater nurses andansthetists.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFund\u003c/strong\u003e:no fund for this case report\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e Written informed consent was obtained from the patient for publi cation of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e:N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e:no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e:All relevant data are within the paper and its Supporting Information files\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMandal, M. K., Sarkar, N., Sarkar, S., \u0026amp; Mollah, J. (2025). A case of appendiculo-ileal knotting as a cause of gangrenous small bowel obstruction in a 64-year-old man in a Government Hospital, West Bengal, India. \u003cem\u003eInternational Surgery Journal\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(8), 1383\u0026ndash;1386. https://doi.org/10.18203/2349-2902.isj20252295\u003c/li\u003e\n\u003cli\u003eAbule T, Chebo T, Billoro BB. 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World J SGastrointest Surg 2015;7(4):67\u0026ndash;70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"bowel obstruction, appendicitis, appendicoileal knotting, double loop obstruction, intraoperative surprise","lastPublishedDoi":"10.21203/rs.3.rs-7860119/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7860119/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSmall bowel obstruction is the common caus of acute abdomen for which emergency surgical intervention is mandatory. Bowel knottings like ileosigmoid knotting, ileoileal knotting,ileocecal knotting and appendicoileal knottings are rare ocurrances as a cause of obstruction.Among these appendicoileal knotting is by far the rarest cause of obstruction. Since its 1st report in 1901, there are case reports of this scenario but all associated it with the presence of appendicitis. We report a 28yrs old female patient who presented with sign symptom of small bowel obstruction for whom appendico-ileal knotting is identified with healthy looking appendix rapped around the distal ileum which was a near miss bowel segment which later returned healthy after the appendix release and warm saline socked sterile pack rapped for a minutes.Appendicoileal knotting can occur in the absence of preceding appendicitis.\u003c/p\u003e","manuscriptTitle":"Appendico-ileal knotting a rare cause of small bowel obstruction; case report and literature review from Leku general hospital,Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:43:13","doi":"10.21203/rs.3.rs-7860119/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f1c5dec8-d2a5-4de3-8301-667a637b99f0","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56288874,"name":"General Surgery"}],"tags":[],"updatedAt":"2025-10-17T12:43:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 12:43:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7860119","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7860119","identity":"rs-7860119","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}