Appendicular Tourniquet: A Cause of Intestinal Obstruction

Abstract

A 73-year-old male patient presented to the casualty with history of pain abdomen since 3 days, abdominal distension, inability to pass flatus and vomiting since 2 days and fever since 1 day. Patient had history of surgery 6 years ago. He had undergone a laparotomy for drainage of appendicular abscess. However, patient was unsure whether an appendectomy was done and there were no records of previous surgery. No other significant history could be elicited. On examination, patient was tachycardic, tachypnoeic and mildly dehydrated. Patient's abdomen was distended and there was a right paramedian and drain scar in the right iliac fossa. His bowel sounds were exaggerated. Ryle's tube was inserted and aspirate had feculent material. Patient was resuscitated with intravenous fluids and routine investigations were sent. Patient's erect abdominal X-ray had multiple air-fluid levels and features were suggestive of small bowel obstruction [Table/ Fig-1]. Ultrasound of the abdomen showed dilated small bowel loops with to and fro motion and appendix could not be visualized. With a preoperative diagnosis of small bowel obstruction secondary to postoperative adhesions, patient was posted for an exploratory laparotomy after taking an informed and written consent. Intraoperatively, no significant adhesions were found but the appendix was inflamed and had curled around the terminal ileum. The appendix was acting as a tourniquet around the terminal ileum about 8-10 cm from the ileocaecal junction and was causing the obstruction [Table / Fig-2,3]. Appendectomy and a mid-ileal enterotomy to empty the small bowel content were performed. Postoperatively, the patient recovered well and was sent home six days after surgery.Histopathological examination of the specimen revealed confluent mucosal ulceration and replacement of the mucosal layer by purulent debris. There was a transmural inflammation noted consisting of neutrophils and occasional eosinophils. These microscopic findings confirmed the intraoperative finding of acute appendicitis. Intestinal obstruction is one of the common surgical emergencies seen in daily practice. Postoperative adhesions are notorious for being the most common cause for intestinal obstruction. Occasionally, laparotomy findings do come as a surprise to surgeons. Here one such case is discussed. A patient was operated on with suspicion of intestinal obstruction secondary to postoperative adhesions. However, laparotomy revealed the appendix to be inflamed, curled around the terminal ileum and acting as a tourniquet. Surgery Section

Internal hernia strangulated on appendicular tourniquet: a case report of an exceptional anomaly of the appendix revealed by a rare hernia

“…This is a rare pathological situation. In 2016, Chowdary [4] identified only 16 published cases. Adhesion of the appendicular tip is thought to be related to the inflammatory process and peritoneal reaction in response to appendicitis [8].…”

“…Some forms of appendicitis can cause bowel obstruction [1, 2]. Among these forms, some authors have described the appendicular tourniquet [3, 4]. It is an ileocecal appendix that forms a loop in which the small bowel can penetrate and perform an internal hernia.…”

Appendico ilial knotting: a rare cause of small bowel obstruction

“…Strangulation can be due to the appendix wrapping around the base of a bowel loop, or when inflamed appendix adheres to caecum, small intestine or posterior peritoneum and a part of the bowel herniates through the gap. This is described with appendicular KNOT, appendicular tourniquet, appendiceal tie syndrome and appendico-ilial knotting [ 6 , 7 , 9 , 10 ]. in our opinion, appendico-ilial knotting is the preferred name because it describes the pathologies of both appendix and ilium.…”

“…The four-cardinal sign and symptoms are colicky abdominal pain, vomiting, absolute constipation, and abdominal distension [ 6 ]. As depicted in the table, most of the patients with appendico-ilial knotting presented with abdominal pain, vomiting and constipation [ 4 – 10 ] Chatterjee suggest that a period of acute appendicitis precedes the mechanical obstruction. CT scan of abdomen can suggest the diagnosis preoperatively.…”

Intestinal obstruction caused by low-grade appendiceal mucinous neoplasm: A case report and review of the literature

“…To the best of our knowledge, intestinal obstructions caused by external compression by a twisted appendix or a mucocele are extremely rare, and only a few cases have been reported on; only 16 [ 7 ] and 6 cases [ [8] , [9] , [10] , [11] , [12] , [13] ] have been reported in the English literature, respectively. Seven cases, including the present case of a mucocele of the appendix, were reviewed in the present study ( Table 1 ).…”