you have a knot in your stomach...

About once a week (sometimes daily) I cut into someone and find something that mystifies me. Monday we had three exploratory abdominal operations for patients with peritonitis (severe abdominal pain).  Most of the time we find a typhoid perforation, a perforated stomach ulcer, or ruptured appendicitis. Sometimes its another surprise...The first laparotomy (done by one of my partners) was a sigmoid volvulus (the sigmoid colon twisted around itself).  Sigmoid volvulus is also relatively common around here- seems like we operate for one every few weeks.

Removing the redundant sigmoid colon. 

When I opened the second patient's abdomen, I found some gangrenous small intestine and large intestine. The weird thing was, the small and large intestine and their blood supplies were all twisted around each other. I couldn't figure out how to get them untwisted, no matter which way I turned them. They were just all wrapped too tightly together and the intestine was very fragile because its blood supply had been cut off for at least a day.

The intestine  looked kind of like this, except this ileosigmoid knot has been untwisted

I've operated on twisted bowel (called a volvulus) many times...but I'd never seen (or heard) about the small and large bowel getting twisted around each other. Well, guess what? Its a real thing, your intestines can literally tie themselves in a knot. I searched Google for answers after the operation and discovered that what I found is called a ileosigmoid knot or double volvulus. It is more common in African countries- for some reason (likely related to genetics and/or diet) many African's have longer colons that twist on themselves more easily.

When bowel twists on itself, the blood supply gets cut off and the intestine dies if you don't untwist it soon enough.His twisted bowel was dead, so I cut out both sections and dead bowel and made new connections. When I finished, I tried to draw out what I had found so I could understand it better. This is what had happened:

The shaded part represents the dead bowel. 

another view

The few articles I read said that the mortality rate after operating on an ileosigmoid knot is very high. Forty to fifty percent of people die soon after the operation, especially when the bowel is dead (this man's bowel was very dead). Happily, he is doing very well and has started drinking liquids 3 days after the operation!