ileosigmoid knotting is rare cause of acute abdomen . it is more commonly seen in parts of africa , asia , and the middle east but less so in other parts of the world like the uk where reports are sporadic . parker first described the condition in 1845 ; since then , over new cases have been reported from different parts of the world , but the exact incidence is not known . it occurs commonly in men in their fourth decade but has been reported in children also , even in neonate . this is a report of two cases of isk in patients under 25 years of age , managed by the authors in university of port harcourt teaching hospital ( upth ) , port harcourt , nigeria . the first was a 21-year - old male who presented with a history of sudden generalized abdominal pain of two days duration . an erect plain abdominal radiograph showed multiple air fluid levels while the supine showed 3 curved lines of dilated bowel converging to the pelvis . nasogastric tube was passed and urethral catherterization was done to monitor urine output . within a few hours of admission , he had an exploratory laparotomy . findings were as follows : ileo - sigmoid knotting with gangrene of the sigmoid and distal loop of ileum ( figs . he had sigmoidectomy with end colostomy ( hartmann 's procedure ) and right hemicolectomy with ileo - transverse anastomosis . the second case was a 20-year - old male who presented with a history of sudden generalized abdominal pain of three days duration . an erect plain abdominal radiograph showed multiple air fluid levels while the supine showed 3 curved lines of dilated bowel converging to the pelvis fig . he was resuscitated with intravenous fluids ( normal saline , dextrose infusion ) , antibiotics ( ceftriaxone 1  gm , metronidazole 500  mg ) and analgesics . nasogastric tube was passed . he had careful detorsion , sigmoidectomy with primary anastomosis as his sigmoid colon was redundant fig . the first was a 21-year - old male who presented with a history of sudden generalized abdominal pain of two days duration . an erect plain abdominal radiograph showed multiple air fluid levels while the supine showed 3 curved lines of dilated bowel converging to the pelvis . nasogastric tube was passed and urethral catherterization was done to monitor urine output . within a few hours of admission , he had an exploratory laparotomy . findings were as follows : ileo - sigmoid knotting with gangrene of the sigmoid and distal loop of ileum ( figs . he had sigmoidectomy with end colostomy ( hartmann 's procedure ) and right hemicolectomy with ileo - transverse anastomosis . the second case was a 20-year - old male who presented with a history of sudden generalized abdominal pain of three days duration . an erect plain abdominal radiograph showed multiple air fluid levels while the supine showed 3 curved lines of dilated bowel converging to the pelvis fig . he was resuscitated with intravenous fluids ( normal saline , dextrose infusion ) , antibiotics ( ceftriaxone 1  gm , metronidazole 500  mg ) and analgesics . nasogastric tube was passed . he had careful detorsion , sigmoidectomy with primary anastomosis as his sigmoid colon was redundant fig . ileosigmoid knotting is a very rare cause of intestinal obstruction , occurring in men in their fourth decade . it is also referred to as compound volvulus or double volvulus but recently raveenthiran has suggested that the correct terminology should be compound volvulus . jebbin in mile one hospital port harcourt , nigeria , reported two cases of ileo - sigmoid knotting , but this occurred in patient aged 51 and 50 years , respectively . these include a long small intestine mesentery with a freely mobile small bowel , a long sigmoid loop on a narrow  v shaped pedicle , and the consumption of a high bulk diet in the presence of an empty small bowel . meckel 's diverticulum has been reported to be present in 1453% of cases while a relaxed anterior abdominal wall , as commonly seen in postpartum has also been implicated . in his description , loops of ileum descend into the left paracolic gutter and wraps around the sigmoid colon , both becoming distended sooner or later . with time , both loops of ileum and sigmoid become strangulated , the latter more frequently so . gangrene ensues eventually , and may extend to the terminal ileum , sometimes involving the caecum and in very rare occasion , the proximal ascending colon . the diagnosis of isk is infrequently made before surgery , this being possible only in about 20% 0f patients . any patient previously in a good state of health and developing a sudden onset of colicky abdominal pain , other features of intestinal obstruction , and in a shock state , all occurring in rapid succession should arouse a suspicion of isk . white blood cell count usually shows leukocytosis due to gangrene and it is thus not specific for isk . plain abdominal radiographs may show characteristic double closed loop obstruction , with the sigmoid on the right upper quadrant and the small bowel loops on the left but this is only an occasional finding . more often , the picture is either that of simple sigmoid volvulus or small bowel obstruction but the former is predominant . these include the  whirl sign , created by the twisted intestines and mesentery , and medial deviation of the descending colon with a beak appearance on its medial border . this investigation was not done in first case because patient presented in shock and for the second case , the machine was not in a good functional state in port harcourt at the time patient presented . survival in this rare but serious condition hinges on aggressive resuscitation and early surgical intervention . the diagnosis of intestinal obstruction without a definite pathology is a sufficient indication for a laparotomy . it has been observed that accurate diagnosis is not an end in itself but a means to providing an appropriate treatment . the surgical option depended on findings at laparotomy . with viable intestinal loops , untying the knot alone other authors advocate resection of the sigmoid colon in all cases or mesosigmoidoplasy to avert recurrence . when the bowel loops are gangrenous , most authors recommend the knots should not be unraveled as this can lead to bowel perforation and septic shock . gangrene of both loops of bowel will demand en block resection of the knot and double primary anastomosis of ileal and sigmoid ends . however , if gangrene extends to less than 10  cm from the ileocaecal junction , a right hemicolectomy is recommended . this was the option adopted in the cases presented in recent times , primary anastomoses after sigmoid resection could be done without any form of bowel preparation as in the second case reported . other options include closure of the distal ileal stump and end - to - end ileocolic anastomosis . the disadvantage of this is that the bypassed portion of the intestine , known as the blind loop , often initiates a cascade of problems known as the blind loop syndrome . there was no consensus in literature as to which bowel should be resected first , ileum or sigmoid ? the authors recommend resection of sigmoid enbloc first before the ileum as this may allow recovery of more segments of the later before considering right hemicolectomy . the mortality rate of non - gangrenous isk ranges from 6.8% to 8% . for gangrenous cases , poor prognostic factors include age over 60 years , duration of symptoms longer than 24  h , and extensive bowel gangrene . though this condition is more common in fourth or fifth decade of life , can also occur in the second decade . the prognosis used to be very poor but currently , with early diagnosis , aggressive resuscitation , potent broad spectrum antibiotics and advances in anaesthesia with modern post - operative intensive care , the outcome is improving . primary anstomosis of the left colon without any form of bowel preparation can be done especially when patients condition permits . first presentation : international college of surgeons ( ics ) conference nigerian national section ile - ife 2013 . second presentation : international college of surgeons ( ics ) conference asian pacific federation congress 2013 ( apfc held in thailand ) . case study design and writing was by author : patrick okechukwu igwe . contributing authors :
introductionileosigmoid knotting is a rare cause of acute abdomen with high morbidity and mortality . 
 its diagnosis is infrequently made before surgery because of its varying ways of presentation and rarity.presentation of casethe first was a 21-year - old male who presented with a history of sudden generalized abdominal pain and progressive abdominal distension . 
 he was pale and severely dehydrated . 
 his extremities were cold and clammy . 
 his pulse rate was 110 per minute and blood pressure was 90/50  mmhg.the second case was 20-year - old male who presented with similar symptoms as above . 
 he was not pale but mildly dehydrated . 
 his pulse rate was 92 per minute and blood pressure 110/70  mmhg.both patients were resuscitated and had exploratory laparotomy a few hours after presentation . 
 the first patient was found to have ileosigmoid knotting with gangrenous sigmoid colon and terminal ileum . 
 he had hartmann 's procedure and right hemicolectomy with ileo - transverse anastomosis.the second patient was found to have ileosigmoid knotting with viable loops of bowel . 
 he had careful detorsion , sigmoidectomy with primary anastomosis . 
 both patients have good outcome.discussionthis is to report two cases of ileosigmoid knotting in two male patients aged 21 and 20 years , respectively , with the hope of increasing awareness.conclusionileosigmoid knotting though more common in fourth or fifth decade of life , can also occur in the 2nd decade . 
 early diagnosis , careful resuscitation and skilful surgical intervention will improve outcome .