Appendicular knot - an exceptionally rare "two in one case" of acute abdomen.

Sir,

We read the report by Yagnik et al.[1] with interest and report a similar “two in one” case of acute abdomen detected intraoperatively. A 25-year-old gentleman reported to the emergency room with complaints of right iliac fossa pain and abdominal distention since the last 24 h. This was associated with nausea, vomiting, and absolute constipation. Abdomen was distended with guarding and rigidity that was confined to the right iliac fossa. Bowel sounds were hyper-peristaltic. Examination revealed blood pressure of 100/70 mmHg, pulse rate of 100/min, and temperature of 39°C. Laboratory data showed white cell count of 19,000/mm3 with left shift. Plain radiograph of the abdomen, erect and supine, revealed features of intestinal obstruction. Ultrasound of abdomen was suggestive of gaseous bowel loops and some free fluid in the right iliac fossa. Exploratory laparotomy revealed small bowel obstruction caused by knotting due to encircling of the small bowel by gangrenous appendix. This was associated with internal herniation of the appendix through the mesentery of the small bowel [Figures 1 and 2]. The knot was untied by detaching the tip of the appendix (appendix had encircled the ileum with its tip getting fixed to the caecum) and the obstruction was relieved. The bowel was healthy and as the obstruction was completely relieved, only appendicectomy was performed. The patient had an uneventful recovery.

Figure 1

The knot by the gangrenous appendix encircling the small bowel

Figure 2

The internal herniation by appendix through the mesentery

Although Meckel's diverticulum as a cause of knotting of ileum has been reported in the literature, knotting by inflamed appendix is extremely rare and no such case has been reported to the best of our knowledge.[12]