Introduction
Parker E described the first patient of ileosigmoid knotting in 1845 [1]. The first patient from the Asian subcontinent was reported by Paul M in 1940 [2]. First patient-reported from Africa by Burkitt D in 1952 [3]. The first case from India was reported by Dunkertey GE in 1953 [4]. Ileosigmoid knotting, the name first given by Shepherd JJ in 1967 [5]. Ileosigmoid knotting is a very rare cause of intestinal obstruction [1]. It occurs due to the wrapping of the ileum or sigmoid colon around the base of the other one, which may cause double-loop intestinal obstruction and/or gangrene of both the loops [6]. It is a well-recognised condition in certain African, Asian, and Middle Eastern nations; but is uncommon in the western world [7]. The patient is usually haemodynamically unstable during presentation due to gangrene of one or both the limb. The patient usually presented with abdominal pain, rapid abdominal distention, and vomiting with rebound tenderness and hyperactive bowel sound. Preoperative diagnosis is difficult because the condition is very rare, and radiographic findings are not able to differentiate from other causes of intestinal obstruction. Usually, diagnosis is made intraoperatively. The most important differential diagnosis is sigmoid volvulus because endoscopic reduction is a contraindication in Ileosigmoid knotting. CECT with oral and rectal contrast is helpful in making a preoperative diagnosis but not available in many institutions in emergency settings. Generalised peritonitis with sepsis is the main cause of poor outcome [8]. Immediate surgical intervention with resection of gangrenous part with anastomosis or stoma formation is the only available treatment. This article focuses on the aetiopathogenesis, presentation, diagnostic modalities, surgical interventions, and outcome with the review of articles and case series published to date.
Review of Literature
Studies and case reports were identified by PubMed, MEDLINE, ISIS, Embase, and CAS searches with the following free text keywords: ileosigmoid knotting, intestinal knotting, compound volvulus and double volvulus in English literature. Other sources included review articles and textbooks. The authors also added a case of ileosigmoid knotting encountered in the surgical emergency.
Data was collected from all available case series and reports from the literature. A total of 38 articles were identified [Table/Fig-1] [1,2,4-39].
Different case reports and series of ileosigmoid knotting described in literature till date [1,2,4-39].
| Serial no. | Year | Author | Total cases | Country | Age group (mean) | Sex | Predisposing factors | Alver O et al., Classification (1993) | Investigation | Preoperative diagnosis made | Outcome |
|---|
| Male | Female | Yes | None | I | II | III | IV | X-ray | CT scan | Yes | No |
|---|
| 1 | 1845 | Parker E [1] | 1 | UK | 53 | 1 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | NA | NA | NA | NA | NA |
| 2 | 1932 | Kallio KE [9] | 1 | Finland | 48 | 1 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | NA | NA | NA | NA | Alive |
| 3 | 1940 | Paul M [2] | 1 | Ceylon | NA | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | NA | NA | NA | NA | Alive |
| 4 | 1953 | Dunkerley GE [4] | 1 | India | 61 | 1 | 0 | 0 | 1 | NA | NA | NA | NA | NA | NA | NA | NA | Died |
| 5 | 1967 | Shepherd JJ [5] | 92 | Uganda | 42 | 78 | 14 | 12 | 80 | 60 | 19 | 1 | 12 | NA | NA | NA | NA | 20-died |
| 6 | 1973 | Roy SP et al., [11] | 9 | India | 39 | 7 | 2 | 2 | 7 | NA | NA | NA | NA | 8 | 0 | 0 | 9 | 1-died |
| 7 | 1981 | Kakar A and Bhatnagar BN [12] | 11 | India | 38 | 6 | 5 | 2 | 9 | NA | NA | NA | NA | 11 | 0 | 0 | 11 | NA |
| 8 | 1984 | Watson RG [13] | 7 | South Africa | NA | NA | NA | 1 | 6 | NA | NA | NA | NA | 5 | 0 | 0 | 7 | 2-died |
| 9 | 1986 | Johnson CD [14] | 1 | UK | NA | NA | NA | 0 | 1 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | Died |
| 10 | 1991 | Puthu D et al., [8] | 7 | India | 40 | 4 | 3 | 1 | 6 | 5 | 1 | 0 | 1 | 7 | 1 | 1 | 6 | 4-died |
| 11 | 1992 | Guessan HA et al., [10] | 16 | Abidjan | 42 | 10 | 6 | 1 | 11 | NA | NA | NA | NA | NA | NA | NA | NA | 7-died |
| 12 | 1993 | Gibney EJ and Mock CN [15] | 15 | Ghana | NA | 11 | 4 | 1 | 14 | NA | NA | NA | NA | 14 | 2 | 0 | 15 | 2-died |
| 13 | 1993 | Alver O et al., [7] | 68 | Turkey | 49 | 57 | 11 | 10 | 58 | 45 | 12 | 3 | 8 | 62 | 3 | 2 | 66 | 14-died |
| 14 | 1997 | Akgun Y [16] | 16 | Turkey | 45 | 11 | 5 | 2 | 14 | 8 | 3 | 1 | 4 | 13 | 0 | 1 | 15 | 3-died |
| 15 | 1998 | Kedir M et al., [17] | 1 | Ethiopia | NA | NA | NA | 0 | 1 | NA | NA | NA | NA | NA | NA | NA | NA | NA |
| 16 | 2001 | Raveenthiran V [18] | 7 | India | 43 | 6 | 1 | 1 | 6 | 5 | 0 | 0 | 2 | 6 | 0 | NA | NA | 3-died |
| 17 | 2002 | Nasir GAA and Mohammed MM [19] | 7 | Iraq | NA | 5 | 2 | 0 | 7 | 4 | 1 | 0 | 2 | 7 | 0 | 0 | 7 | 1-died |
| 18 | 2004 | Hashimoto T et al., [20] | 2 | Japan | 32 | 2 | 0 | 0 | 2 | 2 | 0 | 0 | 0 | NA | NA | 0 | 2 | 1-died |
| 19 | 2004 | Atamanalp SS et al., [6] | 63 | Turkey | 47 | 47 | 16 | 6 | 57 | 49 | 5 | 1 | 8 | 57 | 2 | 1 | 62 | 13-died |
| 20 | 2007 | Jebbin NJ [21] | 2 | Nigeria | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | All alive |
| 21 | 2008 | Bawa D et al., [22] | 1 | Nigeria | 26 | 1 | 0 | 0 | 1 | NA | NA | NA | NA | 1 | 0 | NA | NA | NA |
| 22 | 2009 | Machado NO [23] | 1 | Muscat | 52 | 1 | 0 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | Alive |
| 23 | 2009 | Zahid FE et al., [24] | 1 | Morocco | 42 | 1 | 0 | NA | NA | NA | NA | NA | NA | 1 | 0 | NA | NA | Died |
| 24 | 2009 | Alvi AR et al., [25] | 2 | Karachi | 44 | 2 | 0 | 1 | 1 | 2 | 0 | 0 | 0 | NA | NA | 0 | 2 | 1-died |
| 25 | 2009 | Atamanalp SS et al., [26] | 71 | Turkey | 37 | 50 | 21 | 20 | 51 | 52 | 8 | 1 | 10 | 66 | 2 | 1 | 70 | 20-died |
| 26 | 2009 | Okello TR et al., [27] | 44 | Uganda | 39 | 36 | 8 | 8 | 36 | 34 | 4 | 2 | 4 | 35 | 0 | 0 | 44 | 13-died |
| 27 | 2011 | Ahmadi nazad M et al., [28] | 1 | Iran | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | Alive |
| 28 | 2011 | Baheti AD et al., [29] | 1 | India | 51 | 1 | 0 | NA | NA | NA | NA | NA | NA | 1 | 0 | 0 | 1 | Alive |
| 29 | 2011 | Atamanalp SS [30] | 32 | Turkey | 41 | 21 | 11 | 11 | 21 | 21 | 6 | 1 | 4 | 30 | 1 | 1 | 31 | 7-died |
| 30 | 2014 | Banerjee C [31] | 9 | India | 47 | 8 | 1 | 2 | 7 | NA | NA | NA | NA | 9 | 0 | NA | NA | 2-died |
| 31 | 2012 | Uday SK et al., [32] | 1 | India | 32 | 1 | 0 | NA | NA | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | Alive |
| 32 | 2013 | Kumar S et al., [33] | 1 | India | 46 | 1 | 0 | NA | NA | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | Alive |
| 33 | 2014 | Igwe PO [34] | 2 | Nigeria | 21 | 2 | 0 | 0 | 2 | 2 | 0 | 0 | 0 | 2 | 0 | 0 | 2 | Alive |
| 34 | 2014 | Andromanakos N et al., [35] | 1 | Greece | NA | NA | NA | 0 | 1 | NA | NA | NA | NA | NA | NA | NA | NA | Died |
| 35 | 2014 | Shimizu R et al., [36] | 1 | Japan | NA | NA | NA | 0 | 1 | NA | NA | NA | NA | 1 | 0 | NA | NA | Alive |
| 36 | 2014 | Bhambare M et al., [37] | 1 | India | NA | NA | NA | 1 | 0 | NA | NA | NA | NA | 1 | 0 | 0 | 1 | Alive |
| 37 | 2014 | Yazough I et al., [38] | 1 | Africa | 61 | 0 | 1 | NA | NA | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | Alive |
| 38 | 2016 | Islam S et al., [39] | 2 | Pakistan | NA | NA | NA | 1 | 1 | NA | NA | NA | NA | NA | NA | NA | NA | 1-died |
Classification
The classification of the disease was made by Alver O et al., in 1993 by taking the ileum and/or sigmoid colon as the active component and considering the direction of the torsion [7].
Type I (55%)- Ileum (active component) wraps itself around the sigmoid colon (passive component)
Type 1a- clockwise direction
Type 1 b- Anticlockwise direction
Type II (25%)- Sigmoid colon (active component) wraps itself around the ileum (passive component)
Type 1a- clockwise direction
Type 1b- Anticlockwise direction
Type III (5%)- The ileocecal segment (active component) wraps itself around the sigmoid colon (passive component)
Type IV Undetermined (15%)- In this, it is impossible to determine the revolved segment
A new classification was developed by Atamanalp SS et al. [26] in 2008 for ileosigmoid knotting, using mortality criteria, such as age over 60 years, and the presence of accompanying disease or shock. In this proposed classification, the patients were classified as follows:
Class 1: Patients with no risk factor;
Class 2: Patient with no shock or gangrene but with other risk factors, such as age over 60 years, or existence of an associated disease;
Class 3: Patient with shock;
Class 4: Patient with single segment bowel gangrene (ileum or sigmoid colon);
Class 5: Shock and single-segment bowel gangrene;
Class 6: Patient with gangrene in both segments.
Depending on the presence of other risk factors, Class 2, 3, and 4 were further divided into sub-groups of a and b. They studied 71 patients with ileosigmoid knotting that were treated surgically in the Department of General Surgery, School of Medicine, Atatürk University in 42 years period between June, 1966 and July, 2008 [26].
Epidemiology
Ileosigmoid knotting has a higher incidence in East Africa, but it is reported from other parts of the world like Asian, Middle Eastern, Eastern, Northern European, South American countries, and also from Turkey [12-20]. It more commonly affects males who are in the fourth decade of life [5]. Geographical location, racial predilection, habit and diet make the condition common among Africans [10].
Aetiology
Three factors are responsible for the ileosigmoid knotting [7,8,12]
1- A long small bowel mesentery with freely mobile small bowel
2- Ingestion of a high bulk of the diet in the presence of an empty small bowel
3- A long sigmoid colon on a narrow pedicle
Secondary causative factors which are also described in the literature are: late pregnancy, Meckel diverticulitis with a band, trans-mesenteric herniation, ileo-cecal intussusceptions, and floating cecum [7,8]. The consumption of a high bulk diet in the presence of an empty small bowel can be a predisposing factor. Therefore, the incidence is high among Muslims who eat a single daily meal during the Ramadan fast [7].
Pathogenesis
The pathogenesis of ileosigmoid knotting is not clear. Suggested theory is, a semi-liquid bulky meal passing from proximal jejunum to the rest of the bowel, increases the mobility of the rest of the bowel. This causes the heavier segments of the proximal jejunum to shift into the left lower quadrant. Remaining empty loops of ileum and distal jejunum twist in a clockwise rotation around the base of a narrow sigmoid colon. Progressive peristalsis forms an ileosigmoid knot with two closed-loop obstruction in the small bowel and sigmoid colon [7].
In ileosigmoid knotting, there is an obstruction in both ileum and sigmoid colon. Progressively, it causes strangulation, and thrombosis of the vessels leading to ischemia and gangrene in the ileum and sigmoid colon. The gangrene may extend to the proximal part of the ileum, the cecum, and rarely the distal part of the jejunum and ascending colon [7,8]. Obstruction or gangrene causes the release of endotoxin and bacterial translocation in the peritoneal cavity resulting in septicaemia and shock [6-8].
Clinical Features
The patient is usually haemodynamically unstable during presentation due to gangrene of one or both the limbs. The patient usually presented with abdominal pain, rapid abdominal distention, and vomiting. Other complaints include nausea, diarrhoea, anorexia, rectal bleeding, and hematemesis. On examination, the main signs are asymmetrical abdominal distention and generalised tenderness. Additional findings include hyperactive bowel sounds, tympanic sound all over the abdomen, ballooning of rectum, and visible peristalsis [7,8]. It can rapidly progress to gangrene of the ileum and/or sigmoid colon [8]. If not treated immediately, patient may go in generalised peritonitis, sepsis, and dehydration leading to death. In this review of published articles the following observations were made: abdominal pain and tenderness (100%, n-38) [1-2,4-39], abdominal distension (95%, n-37) [1-2,5-39], nausea and vomiting (87%, n-36) [1-2,4-37], rebound tenderness (70%, n-34) were identified [1-2,5-36].
Diagnosis
Preoperative diagnosis is difficult because the patient usually presents with non-specific symptoms in an emergency that mimic the features of small and/or large bowel obstruction. It should be suspected in patients with clinical features suggestive of small bowel obstruction, while the radiographic findings are that of colonic obstruction [18]. Laboratory reports usually show a drop in haemoglobin, leukocytosis, raised Blood Urea Nitrogen (BUN), and electrolyte imbalance suggestive of peritonitis [6]. Plain abdominal X-ray radiographs demonstrate a dilated sigmoid colon and multiple small intestinal air-fluid levels. The X-ray may show free gas under diaphragm due to the perforation of any segment [6,7].
Clinically or on plain X-ray, it is often mistaken for sigmoid volvulus. Sigmoidoscope or a flatus tube may not deflate the distended colon or help to release the ileosigmoid knotting [8,12]. CECT with oral and rectal contrast can help in preoperative diagnosis, but due to the rarity of this condition, even CECT may fail to reach the correct diagnosis [40]. Also, CECT is not available in many institutions in emergency settings. The findings in a CECT scan suggestive of ileosigmoid knotting include the whirl sign. It is created by twisted intestine and sigmoid mesocolon in ileosigmoid knot, medial deviation of the cecum, and descending colon [40,41]. Signs of bowel ischaemia or gangrene caused by strangulation can be seen in a CT scan [42,43]. A flexible sigmoidoscopy can demonstrate a spiral sphincter-like twisting of the mucosa in the sigmoid colon, but it does not give any information about the small bowel [42].
Based on a review of the literature, the fulfillment of these three conditions may reach to correct diagnosis of ileosigmoid knotting [16,18,22,41].
Clinical symptoms of small bowel obstruction like predominant vomiting.
X-ray or CECT evidence of predominately large bowel obstruction involving the sigmoid colon
Inability to insert a sigmoidoscope or flatus tube to relieve symptoms.
If all three features are present, one should raise the suspicion of ileosigmoid knotting.
Treatment
The patient is usually haemodynamically unstable on presentation. So, priority should be given for nasogastric decompression, aggressive resuscitation with fluid and electrolytes with the help of central venous pressure monitoring, or wide bore cannula [6,7]. Correction of acid-base imbalance is very important in these patients as vomiting can be present with hyponatremia and hypokalemia [6,7]. Exploratory laparotomy is the only available treatment and should not be delayed after haemodynamic stabilisation [7]. Broad-spectrum antibiotic therapy is given early and continued after the surgery. The usual antibiotic combination includes cephalosporins/imipenem group, aminoglycosides, and metronidazole [16].
Surgical procedures depend on the viability of single or both loops. Knot may be untwisted if both loops are viable. It can be done by sigmoid enterotomy or needle puncture, if not able to do without it, when the ileum and the sigmoid colon both are gangrenous, the chance of spillage of toxic bowel contents is there during the untying of knot [16]. Intestinal clamps should be applied before untwisting or resection of the knot followed by resection of the gangrenous loop to minimise contamination. The primary anastomosis can be done if both ends of the small or large bowel are viable and bleed well [16]. Hartmann operation or a covering colostomy was recommended previously to avoid the risk of faecal leak from the colonic anastomosis, but recent literature said that primary colonic anastomosis might be undertaken safely when history is short, and the remaining bowel is cleaned and well-vascularised [16].
Primary anastomosis in the gangrenous sigmoid colon can be safely carried out without significant complications [44,45]. Second look laparotomy and anastomosis can be carried out if both ends of the bowel are healthy, had no gross contamination, with a rich blood supply, and if a tension-free anastomosis could be achieved [11,44,45]. In patients with blood pressure <90/60 mm Hg and a pulse >120 beats/min, either preoperatively, or after the induction, despite fluid resuscitation, laparotomy should be considered. This involves en-block resection of the involved segment closure of the bowel edges peritoneal lavage and temporary abdominal closure [46]. As a precaution, a stoma should be used to retain the viability of the stump [44]. Intraoperative colonic irrigation and peritoneal lavage is mandatory even with minimal faecal contamination [18].
Prognostic Factors
The reported mortality in ileosigmoid knotting varies from 2% to 55% (mean 36%) in different studies [16,18,21,22,44,45]. Various prognostic factors are described, out of which the general condition of the patient, presence of shock, presence of gangrene, and total duration of disease are important [47]. The mortality rate is high in gangrenous cases [48]. The morbidity rate is also high [48]. The most common cause of death is shock [42]. A second look surgery or surgery with stoma formation has a high survival rate but more morbidity [16]. A review of the literature revealed that there has been a constant decline in mortality in the last 20 years due to better knowledge of the condition, broad-spectrum antibiotic availability, ICU care, and newer surgical skills [22].
Case Report
A 38-year-old Muslim male patient, was brought in Surgery Emergency Department with a history of generalised abdominal pain, abdominal distention, bilious vomiting, and non-flatus of flatus and stools for two days. The patient also had a history of pulmonary tuberculosis six years back, for which he received Antitubercular Therapy (ATT) for six months.
On examination, his pulse rate was 120/min, BP-80/50 mmHg. Bilateral wheeze were present in the chest. The abdomen was tense and distended with generalised tenderness and guarding. Bowel sounds were absent. Rebound tenderness was present, and on per rectal examination, soft faecal matter was present.
Lab investigation shows hypokalemia and hyponatremia due to excessive vomiting. X-ray erect abdomen revealed multiple air-fluid levels with dilated large bowel suggestive of both small and large bowel obstruction [Table/Fig-2]. There was no gas under the diaphragm in the chest X-ray. Ultrasonography showed multiple dilated bowel loops with minimal interbowel fluid. CECT was not available in an emergency setting.
X-ray shows dilated small and large bowel with an air-fluid level.
After aggressive resuscitation, an urgent exploratory laparotomy was done. Intraoperative findings are: sigmoid colon mesentery was wrapped around ileum (type-2 classification), making two complete turns with gangrene of both sigmoid colon and ileum [Table/Fig-3,4]. Clamps applied, and both gangrenous sigmoid colon and ileum were resected. Double barrel ileostomy with colocolic anastomosis was done because the viability of both ends of ileum was doubtful, and the patient was haemodynamically unstable. The patient remained on ventilator support for one day. However, he improved gradually. Stoma became functional on the second postoperative day, and then he was orally allowed. The patient was discharged after one week with a plan of ileostomy closure after six weeks.
Gangrenous sigmoid colon and ileum.
Conclusion(s)
Ileosigmoid knotting rarely causes intestinal obstruction. Early diagnosis and intervention are necessary for a better outcome. Clinical signs of small bowel obstruction, radiological signs of large bowel obstruction, and failure of hydrostatic reduction may raise the suspicion of Ileosigmoid knotting. But in most of the cases, diagnosis is made intraoperatively. This condition should be differentiated from sigmoid volvulus because it is not relieved by hydrostatic reduction or sigmoidoscopy. Aggressive management with fluid resuscitation, preoperative antibiotics, early laparotomy, optimum surgical technique, and better perioperative care has increased the chance of survival of these patients. In the past, it has a bad prognosis, but now these figures are improving due to the above-mentioned factors.
[1]. Parker E, Case of intestinal obstruction: Sigmoid flexure strangulated by the ileum Edinb Med Surg J 1845 64:306-08. [Google Scholar]
[2]. Paul M, Volvulus of the intestine with intertwining loops The Lancet 1940 236(6122):809-10.10.1016/S0140-6736(01)08406-9 [Google Scholar] [CrossRef]
[3]. Burkitt D, Acute abdomens-British and Baganda compared East Afr Med J 1952 29(5):189-94. [Google Scholar]
[4]. Dunkerley GE, Intestinal obstruction due to knotting of two loops of small intestine Br J Surg 1953 41(165):66-70.10.1002/bjs.1800411651713082012 [Google Scholar] [CrossRef] [PubMed]
[5]. Shepherd JJ, Ninety-two cases of ileosigmoid knotting in Uganda Br J Surg 1967 54(6):561-66.10.1002/bjs.18005406156026331 [Google Scholar] [CrossRef] [PubMed]
[6]. Atamanalp SS, Oren D, Başoğlu M, Yildirgan MI, Balik AA, Polat KY, Ileosigmoidal knotting: Outcome in 63 patients Dis Colon Rectum 2004 47(6):906-10.Epub 2004 May 410.1007/s10350-004-0528-915129310 [Google Scholar] [CrossRef] [PubMed]
[7]. Alver O, Oren D, Tireli M, Kayabasi B, Akdemis D, Ileosigmoid knotting in Turkey: A review of 68 cases Dis Colon Rectum 1993 36(12):1139-47.10.1007/BF020522638253011 [Google Scholar] [CrossRef] [PubMed]
[8]. Puthu D, Rajan N, Shenoy GM, Pai US, The ileosigmoid knot Dis Colon Rectum 1991 34:161-66.10.1007/BF020499921993413 [Google Scholar] [CrossRef] [PubMed]
[9]. Kallio KE, Die Knotenbildungen des Darmes Acta Chir Scand 1932 21(suppl):l-276. [Google Scholar]
[10]. Guessan HA, Keli E, Yapo P, Ileosigmoid knot 16 cases Chirurgie 1992 118(6-7):382-88. [Google Scholar]
[11]. Roy SP, Tay YK, Kozman D, Very rare case of synchronous volvulus of the sigmoid colon and caecum causing large-bowel obstruction BMJ Case Rep 2019 12(1)10.1136/bcr-2018-22737530696645 [Google Scholar] [CrossRef] [PubMed]
[12]. Kakar A, Bhatnagar BN, Ileosigmoid knotting: A clinical study of 11 cases Aust NZJ Surg 1981 51:456-58.10.1111/j.1445-2197.1981.tb05984.x6947787 [Google Scholar] [CrossRef] [PubMed]
[13]. Watson RG, Ileosigmoid knot J R Coll Surg Edinb 1984 29(2):100-02. [Google Scholar]
[14]. Johnson CD, An unusual volvulus- The ileosigmoid knot Postgrad Med J 1986 62:47-49.10.1136/pgmj.62.723.473797364 [Google Scholar] [CrossRef] [PubMed]
[15]. Gibney EJ, Mock CN, Ileosigmoid knotting Dis Colon Rectum 1993 36(9):855-57.10.1007/BF020473838375228 [Google Scholar] [CrossRef] [PubMed]
[16]. Akgun Y, Management of Ileosigmoid knotting Br J Surg 1997 84(5):672-73.10.1046/j.1365-2168.1997.02626.x [Google Scholar] [CrossRef]
[17]. Kedir M, Kotisso B, Messele G, Ileosigmoid knotting in Gondar teaching hospital north-west Ethiopia Ethiopian Medical Journal 1998 36(4):255-60. [Google Scholar]
[18]. Raveenthiran V, The Ileosigmoid knot: New observation and changing trends Dis Colon Rectum 2001 44(8):1196-200.10.1007/BF0223464411535862 [Google Scholar] [CrossRef] [PubMed]
[19]. Al-Nasir GA, Mohammed MM, Ileosigmoid knot review of literatures and record of seven cases IJGE 2002 1(3):54-56. [Google Scholar]
[20]. Hashimoto T, Yamaguchi J, Fujioka H, Okada H, Izawa K, Kanematsu T, Two cases of ileosigmoid knot: The youngest reported patient and CT findings Hepatogastroenterology 2004 51:771-73. [Google Scholar]
[21]. Jebbin NJ, Ileosigmoid knotting: A report of two cases Port Harcourt Med J 2007 1(57):197-200.[Google Scholar]10.4314/phmedj.v1i3.38883 [Google Scholar] [CrossRef]
[22]. Bawa D, Ikenna EC, Ugwu BT, Ileosigmoid knotting: A case for primary anastomosis Niger J Med 2008 17(1):115-17.10.4314/njm.v17i1.3737018390148 [Google Scholar] [CrossRef] [PubMed]
[23]. Machado NO, Ileosigmoid knotting: A case report and literature review of 280 cases Ann Saudi Med 2009 29(5):402-96.10.4103/0256-4947.5517319700901 [Google Scholar] [CrossRef] [PubMed]
[24]. Zahid FE, Majdoub KI, Lamrani J, Mazaz K, Ileosigmoid knot strangles the sigmoid J Emerg Trauma Shock 2009 2(3):216-17.10.4103/0974-2700.5535120009318 [Google Scholar] [CrossRef] [PubMed]
[25]. Alvi AR, Bibi S, Effendi S, Khan S, Ileosigmoid knotting- A rare variant of bowel volvulus Trop Doct 2009 39(4):245-46.10.1258/td.2009.08045819762584 [Google Scholar] [CrossRef] [PubMed]
[26]. Atamanalp SS, Oeztuerk G, Aydinli B, Yildirgan MI, Başoğlu M, Oeren D, A new classification for ileosigmoid knotting Turkish Journal of Medical Sciences 2009 39(4):541-45. [Google Scholar]
[27]. Okello TR, Ogwang DM, Kisa P, Komagum P, Sigmoid Volvulus and Ileosigmoid Knotting at St. Mary’s Hospital Lacor in Gulu, Uganda East and Central African Journal of Surgery 2009 14(2):58-64. [Google Scholar]
[28]. Ahmadinejad M, Khalili P, Soleimani S, Ileosigmoid knotting; a case report GOVARESH 2011 15(2):168-72. [Google Scholar]
[29]. Baheti AD, Patel D, Hira P, Babu D, Ileosigmoid knotting: A case report Indian J Radiol Imaging 2011 21(2):147-49.10.4103/0971-3026.8230121799599 [Google Scholar] [CrossRef] [PubMed]
[30]. Atamanalp SS, Ileosigmoid knotting in the elderly: Outcome of 32 cases over 44.5 years Pak J Med Sci 2011 27(4):812-15. [Google Scholar]
[31]. Banerjee C, Mukhopadhyay M, Roy A, Kumar J, Mukherjee S, Rahman QM, The unusual volvulus: A five year retrospective analysis of nine cases Indian J Surg 2014 76(2):100-03.10.1007/s12262-012-0551-324891772 [Google Scholar] [CrossRef] [PubMed]
[32]. Uday SK, Venkata PKCH, Bhargav PRK, Kumar S, Ileo-ileal knot causing small bowel gangrene: An unusual presentation Int J Case Rep Images 2012 3(5):28-30.10.5348/ijcri-2012-05-121-CR-6 [Google Scholar] [CrossRef]
[33]. Kumar S, Babu R, Rajesh R, Teja N, Reddy C, Ileosigmoid knot in an adolescent Journal of Evolution of Medical and Dental Sciences 2013 2(15):2509-13. [Google Scholar]
[34]. Igwe PO, Jebbin NJ, Dodiyi-Manuel A, Adotey JM, Ileosigmoid knotting in patients under 25 years of age: A report of two cases Int J Surg Case Rep 2014 5(11):824-28.10.1016/j.ijscr.2014.06.01425462043 [Google Scholar] [CrossRef] [PubMed]
[35]. Andromanakos N, Filippou D, Pinis S, Kostakis A, An unusual synchronous ileosigmoid and ileoileal knotting: A case report J Med Case Rep 2014 8(1):20010.1186/1752-1947-8-20024942469 [Google Scholar] [CrossRef] [PubMed]
[36]. Shimizu R, Hoshino Y, Irie H, Ito H, Terauchi T, Kimata M, Ileosigmoid knot at week 13 of pregnancy: Report of a case Int Surg 2014 99(4):230-34.10.9738/INTSURG-D-14-00011.124833144 [Google Scholar] [CrossRef] [PubMed]
[37]. Bhambare M, Waghmare S, Tiwari A, Ileosigmoid knotting-A disastrous double closed loop obstruction Int J Surg Case Rep 2014 5:1035-37.10.1016/j.ijscr.2014.09.03725460467 [Google Scholar] [CrossRef] [PubMed]
[38]. Yazough I, Benhammane H, Morad O, Ossibi PE, Toughrai I, Laalim SA, A rare cause of intestinal obstruction: Ileosigmoid knot Pan Afr Med J 2014 9(19):2110.11604/pamj.2014.19.21.390225584132 [Google Scholar] [CrossRef] [PubMed]
[39]. Islam S, Hosein D, Dan D, Naraynsingh V, Volvulus of ileum: A rare cause of small bowel obstruction BMJ Case Rep 2016 2016:bcr2016216159Published 2016 Sep 1910.1136/bcr-2016-21615927646320 [Google Scholar] [CrossRef] [PubMed]
[40]. Tamura M, Shinagawa M, Funaki Y, Ileosigmoid knot: Computed tomography findings and the mechanism of its formation ANZ J Surg 2004 74(3):184-86.10.1046/j.1445-1433.2003.02793.x14996180 [Google Scholar] [CrossRef] [PubMed]
[41]. Hirano Y, Hara T, Horichi Y, Nozawa H, Nakada K, Oyama AK, Ileosigmoid knot: Case report and CT findings Abdom Imaging 2005 30:674-76.10.1007/s00261-005-0315-715834675 [Google Scholar] [CrossRef] [PubMed]
[42]. Catalano O, Computed tomographic appearance of sigmoid volvulus Abdomen Imaging 1996 21(4):314-17.10.1007/s0026199000718661573 [Google Scholar] [CrossRef] [PubMed]
[43]. Shaff MI, Himmelfarb E, Sacks GA, Burks DD, Kulkarni MV, The whirl sign: A CT finding in volvulus of the large bowel J Comput Assist Tomogr 1985 9(2):410 [Google Scholar]
[44]. Mandal A, Chandel V, Baig S, Ileosigmoid knot Indian J Surg 2012 74(2):136-42.10.1007/s12262-011-0346-y23542502 [Google Scholar] [CrossRef] [PubMed]
[45]. Kumar R, Kumar SKP, Meena K, Singh BK, Ileosigmoid knotting: An unusual cause of acute intestinal obstruction with bowel gangrene BMJ Case Rep 2019 12(5):e226663Published 2019 May 3010.1136/bcr-2018-22666331151967 [Google Scholar] [CrossRef] [PubMed]
[46]. Matthew JM, Scott RS, Twists and turns: A practical approach to volvulus and intussusception Scand J Surg 2010 99(2):93-102.10.1177/14574969100990021020679045 [Google Scholar] [CrossRef] [PubMed]
[47]. Miller BJ, Borrowdale RC, Ileosigmoid knotting: A case report and review Aust NZJ Surg 1992 62:402-04.10.1111/j.1445-2197.1992.tb07213.x1575664 [Google Scholar] [CrossRef] [PubMed]
[48]. Alsam T, Baloch MN, Maher M, Ileosigmoid knotting J Coll Physicians Surg Pak 2007 17:166-67. [Google Scholar]