Epiploic-mesenteric knotting as a rare cause of small-bowel obstruction.

BACKGROUND: Epiploic-mesenteric knotting is an exceptionally rare cause of acute small-bowel obstruction. The condition results from entanglement between the greater omentum and the small-bowel mesentery, creating a true knot that may rapidly progress to strangulation and bowel necrosis if unrecognized.

CASE PRESENTATION: A 56-year-old woman with no previous abdominal surgery presented with a 48-hour history of diffuse abdominal pain, distension, bilious vomiting, and cessation of stool and flatus. Examination revealed abdominal distension with diffuse tenderness and hyperactive bowel sounds. Laboratory tests were unremarkable except for a mild elevation of C-reactive protein. Contrast-enhanced computed tomography demonstrated dilated small-bowel loops with a transition point in the mid-jejunum and a whirl sign of the mesenteric vessels, consistent with a closed-loop obstruction but without an identifiable mechanical cause. Exploratory laparotomy disclosed a tight knot between the greater omentum and the jejunal mesentery, forming an epiploic-mesenteric knot. After gentle detorsion, the bowel regained normal color and peristalsis, and no resection was required. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.

CONCLUSIONS: Epiploic-mesenteric knotting should be considered in patients with small-bowel obstruction of unclear origin, particularly when imaging shows a closed-loop pattern or a whirl sign without an obvious cause. Because ischemia develops rapidly, early surgical exploration remains both diagnostic and lifesaving. Prompt recognition and detorsion can prevent bowel resection and ensure an excellent outcome.