Intestinal obstruction caused by encircling fallopian tube

A 50-year-old woman was admitted to our emergency surgery department with 1-week history of abdominal pain, distension, vomiting and constipation. On examination, she has a distended abdomen with sluggish bowel sounds, but no clinical signs of peritonitis. Blood tests were normal except for the increased white cell count and erythrocyte sedimentation rate (ESR). CT scan with oral as well as intravenous contrast demonstrated the small bowel obstruction without any insight into the aetiology of the disease. Intraoperatively, the right fallopian tube was found to encircle the terminal ileum. A right salpingo-oophorectomy was performed to release the bowel. This case report describes a rare cause of the small bowel obstruction in female patients.

gastrointestinal system, gastrointestinal surgery

The small bowel obstruction is a common cause of acute abdomen with high morbidity and mortality.1–4 Postoperative surgical adhesions remain the most common aetiology.5 Hernia, inflammatory bowel disease and volvulus are other common causes that may lead to the small bowel obstruction.6 We describe an exceedingly rare case of intestinal obstruction by an encircling fallopian tube, which is not reported in the literature to the best of our knowledge. Case presentation A 50-year-old woman was admitted to our emergency surgery department with 1-week history of moderate lower abdominal pain and distension associated with vomiting and inability to pass stool and flatus for the past 3 days. There was no history of any previous intra-abdominal surgery. There was no history suggestive of any prolonged illness. On general examination, she had tachycardia (110 beats/min) with normal blood pressure (110/70 mm Hg). On physical examination, her abdomen was distended with mild tenderness. Bowel sounds were sluggish. There were no signs of peritoneal irritation. Rectal examination revealed hard stool. Investigations The inflammatory markers of the patient were raised (Total Leukocyte Count (TLC)=14.2×109/nL and Erythrocyte Sedimentation Rate (ESR)=42). Electrolytes, renal function and liver function tests were within normal range. On plain X-ray radiography, multiple air fluid levels were seen indicating intestinal obstruction. A CT scan with oral and intravenous contrast was also done. It demonstrated the mildly distended small bowel loops with interileal as well as free peritoneal collection of fluid. Differential diagnosis Intestinal obstruction caused by fecolith or worms. Intestinal obstruction caused by tuberculosis. Treatment The patient was managed aggressively with intravenous fluids. A nasogastric tube was inserted. This settled the patient’s vomiting and improved her abdominal distension. The patient was kept under observation and managed conservatively for 2 days during which her abdominal distension and vomiting was relieved. She was allowed liquid diet on 3rd day. On allowing liquid diet, the patient again developed abdominal distension and recurrent vomiting. So we decided to operate the patient to find out the cause of obstruction. Intraoperatively, approximately 6 cm from the ileocecal junction, a loop of ileum was found to be encircled by a band. On closer inspection, the cause of the obstruction was found to be due to the right fallopian tube wrapping itself around the small bowel (figure 1). A right salpingo-oophorectomy was performed to release the bowel. On inspection, the ovary was dark brown in colour, while the fallopian tube was unremarkable. This completed the operation as the bowel loop encircled by the fallopian tube was healthy and viable (figure 2). There were no other intra-abdominal adhesions present or any other pathology identified which could be attributed to her symptoms. The appendix was healthy with no induration or inflammation. Outcome and follow-up Postoperatively, the nasogastric tube was left for 1 day. The patient was allowed liquid diet from postoperative day 2 and semisolid diet from day 3. Postoperative recovery was uneventful and the patient was discharged after 7 days. The histopathological examination of the resected specimen revealed endometriosis of the ovary. On subsequent follow-up visits, she had no complaints of constipation or obstruction.

The common causes of the small bowel obstruction are postoperative adhesions, hernias, intestinal tuberculosis, malignancy and volvulus.6 Bugmann et al described a case of an ectopic fallopian tube causing strangulation of the ileum in a 14-year-old girl.7 Pines et al described a case of the small bowel obstruction caused by tubo-ovarian abscess due to recurrent pelvic inflammatory disease and intrauterine device.8 Cameron et al described a case of the small bowel obstruction due to herniation through broad ligament and wrapping of fallopian tube around the bowel. The patient had undergone multiple obstetric and gynecologic surgeries in the past.9 In our patient, there was no history of any intra-abdominal surgery. Also, there were no adhesions present inside the abdomen intraoperatively. Kenneth et al described a case of the small bowel obstruction due to intestinal endometriosis.10 In their case, endometriosis implantation on the serosa of the small bowel resulted in twisting of the small bowel causing acute the small bowel obstruction. In our case, the endometriotic ovary got attached to the serosa of terminal ileum and ultimately the fallopian tube wrapped itself around ileum resulting in obstruction of the small bowel. Very rarely, endometriosis can result in complete obstruction of bowel as described by Arafat et al in a case in which endometriosis resulted in complete obstruction of rectosigmoid region.11 Due to complete obstruction, they had to resect the sigmoid colon and make an end colostomy. In our patient, no significant bowel pathology was noted after releasing the adherent ovary, so no bowel resection was done. To the best of our knowledge, there is no published case report on the small bowel obstruction caused by encircling fallopian tube in a patient with no history of any previous intra-abdominal surgery. This is the first case report describing such aetiology. Learning points. This is a rare case of the small bowel obstruction caused by encircling fallopian tube in a female patient. This case report describes a differential of atypical the small bowel obstruction to be considered when faced with a female acute abdomen. This case history also highlights the importance of clinical judgement to direct the decision to operate when faced with the small bowel obstruction of unknown cause, not settling with conservative treatment. Footnotes Contributors: RL planned the procedure and carried it out. RL and PM drafted the paper and conducted a review of the literature. PM revised the paper and created the illustrations. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics statements Patient consent for publication Obtained.

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