Not What It Seems! A Case of Incompetent Ileocecal Valve and Severe Small Bowel Ileus Mimicking Pneumoperitoneum

Introduction: Incompetent ileocecal valve is a rare condition which can resemble other gastrointestinal disorders posing significant diagnostic challenges. There is paucity of data regarding this condition and its manifestations. Our case is of a man patient that presented with recurrent severe small bowel ileus mimicking pneuperitoneum. Exploratory laparotomy revealed no perforation and incompetent ileocecal valve. Case Description/Methods: A 69-year-old man with history of mid gut volvulus status post laparoscopic lysis of adhesions and recent gastric ulcer with visible vessel post dual therapy presented with 4 days of cramping, left lower quadrant pain. Physical exam showed abdominal distension and diffuse tenderness. Labs revealed leukocytosis, anemia and hyperkalemia. Abdominal x-ray revealed a massively dilated loop of the large bowel suggestive of sigmoid volvulus. Patient underwent emergent colonoscopic decompression by GI service. No resistance, strictures, gross lesions, or masses were found. However, no clear loop detorsion was appreciated during procedure. A post colonoscopy abdominal x-ray showed diffuse lucency throughout the abdomen with visualization of the wall of the bowel loops, concerning for Rigler’s sign and free intraperitoneal air. Abdominal CT scan indicated severe free air concerning for perforation (Figure 1). Patient examination showed mildly distended, tympanic, soft and non-tender abdomen, without peritoneal signs. Emergent exploratory laparotomy revealed no evidence of hollow viscus perforation, severely distended small bowel and incompetent ileocecal valve. The patient was further managed with supportive care, showing symptomatic improvement and was eventually discharged with outpatient GI and surgery follow up. Discussion: Ileocecal valve incompetence is a rare and scarcely described condition, that leads to backflow of fecal matter and gas from the large intestine into the small intestine and disruption normal digestive process, resulting in several complications such as SIBO, ileus or bowel volvulus. Radiological findings can imitate the presence of pneumoperitoneum, leading to unnecessary surgical or endoscopic interventions, which was the case with our patient. The absence of specific diagnostic tools makes the prompt diagnosis of this entity difficult, however it is imperative that clinicians consider it as a differential diagnosis in the setting of pneumoperitoneum, particularly with severe distension of small bowel, in order to avoid high risk, unnecessary invasive procedures.Figure 1.: Transverse (A) and sagittal (B) view on CT abdomen obtained before exploratory laparotomy showing severe pneumoperitoneum.