# Ileo-Ileal Knot with Three Closed Loops: A Case Report and Review of Pathophysiology

## TL;DR

This case report describes a rare ileo-ileal knot with three closed loops, highlighting its diagnosis and surgical management.

## Contribution

The report presents a unique case with three closed loops, offering new insights into the diagnosis and surgical approach for ileo-ileal knots.

## Key findings

- The patient's CT scan showed three closed loops, including two tied loops and one knotting loop.
- Emergency laparoscopic surgery was converted to open surgery due to the complexity of the knot.
- Postoperative fibrosis led to a second bowel obstruction requiring resection.

## Abstract

The ileo-ileal knot is a rare condition in which 2 ileal loops form a knot, leading to obstruction, ischemia, and the need for urgent surgical intervention. It is challenging to diagnose preoperatively, with 2 closed loops on CT scan as its characteristic feature. This case revealed 3 nearly situated closed loops, which offers insights into the diagnosis and management of the ileo-ileal knot.

A 69-year-old female patient presented with a 3-h history of upper abdominal pain and repeated vomiting. Contrast-enhanced CT scan revealed a poorly enhanced small-bowel obstruction, with 3 nearly situated closed loops. The patient was diagnosed with a strangulated small-bowel obstruction, likely caused by an unusual internal hernia. Emergency laparoscopic surgery was performed. Due to the difficulty in assessing the intestinal condition and the risk of injury, the procedure was converted to open surgery. Direct evaluation during laparotomy confirmed the diagnosis of an ileo-ileal knot. The knot was untied, further improving bowel color and peristalsis and allowing bowel preservation. Based on the retrospective evaluation of the reconstructed CT scan images and intraoperative findings, the 3 closed loops comprised 2 tied loops and 1 knotting loop. The patient initially recovered. However, she was readmitted on postoperative day 24 due to bowel obstruction caused by fibrosis near the terminal ileum. After undergoing ileocolic resection, the patient recovered uneventfully.

An ileo-ileal knot should be considered in cases of strangulated bowel obstruction with more than 2 closed loops. Because the intraoperative assessment of the knot is challenging, laparoscopic surgery can be difficult. Therefore, early conversion to laparotomy should be considered.