From ruptured ovarian cyst to ileo-ileal knotting: a case of diagnostic dilemma.

Ileo-ileal knotting is a rare, life-threatening cause of small bowel strangulation. Preoperative diagnosis is challenging, and hemorrhagic ascites in reproductive-age women may mimic gynecologic emergencies. A 33-year-old Ethiopian female presented with sudden abdominal pain, vomiting, obstipation, and hemorrhagic shock. Ultrasonography showed dilated small bowel loops and echogenic free fluid, suggesting ruptured ovarian cyst. Due to instability, computed tomography was omitted. Emergency laparotomy revealed 2000 ml of hemorrhagic ascites with normal ovaries and no gynecologic bleeding. An ileo-ileal knot with 180 cm of gangrenous bowel was found; hemorrhagic ascites resulted from transmural ischemia with venous congestion. The gangrenous segment was resected, and stoma created. Short bowel syndrome ensued. Staged jejuno-ileal anastomosis was performed 1 week later with good recovery. This case confirms that hemorrhagic ascites in women does not exclude intestinal strangulation. Early surgical exploration is lifesaving when closed-loop obstruction is suspected.