ABSTRACT We report a case of 65 year female with 7 days history of pain in abdomen, vomiting, constipation and abdominal distension. X-Rays abdomen showed multiple air fluid levels and dilated small bowel loops. Ultrasound abdomen showed dilated gut loops and stone in the gall bladder.Exploratory laparotomy was done and a single 4×3 cm round stone with smooth surface was found in terminal ileum.

KEY WORDS

Enterolith, gall stone ileus, small bowel obstruction.

INTRODUCTION

Small bowel obstruction is mostly due to adhesions after surgery. Small bowel obstruction due to stone impaction is very rare, with most cases caused by gall stone ileus.1,2 In small bowel obstruction gall stone ileus occurs when a gall stone is passed through a biliary-enteric fistula.Gall stone ileus is a well known entity and considered as differential diagnosis of small bowel obstruction.Primary enterolithare formed in the small bowel where as secondaryenterolith are  formed in the gall bladder. Proximal  bowelenterolith are usually composed of bile acids,while those in the distal small bowel are mainly composed of calcium salts. Primary enterolith, where stone is formed in the small bowel,3 are rare cause of small bowel obstruction, and mainly has been seen in association with diverticula4and crohns5disease.But our case is unique because there was no associated diverticula6 and crohns disease.5

CASE REPORT

A 65 year female presented with 7 days history of abdominal pain, vomiting,constipation and abdominal distension. Her initial diagnosis was small bowel obstruction, as her abdomen was distended and bowel sound were absent. Total leucocyte count was 8850. X-rays abdomen showed multiple air fluid level and dilated gut loops. Ultrasound abdomen showed dilated gut loops with stone in the gallbladder.Exploratory laparotomy was done and a hard non mobile mass was palpated 1 feet proximal to ileocaecal junction.Small bowel was dilated proximally and collapsed distally. The entire bowel was examined carefully and no diverticula were identified. A 4×3 cm stone was found impacted in terminal ileum (Figure 1). The gall bladder was found to be normal with no biliary-enteric fistula. The stone was greyish hard and with smooth surface (Figure 2) and was removed via a small enterotomy and margin were sent for histopathological examination. Patient recovered well and was discharged on 10th post operative day. The stone weight was 25 grams and analysis revealed it was composed of calcium oxalate.Histopathological examination of enterotomy margin did not reveal any pathology.

 

DISCUSSION

We reported a rare case of proximal small bowel obstruction due to primary calcium oxalateenterolith without associated diverticula or crohns disease. It is postulated that diverticulas provide more acidic environment necessary for choleric acid precipitation and stone formation. However calcification can not occur without an alkaline pH shift, which normally occurs in the ileum.7Our case is unique, as there was no associated diverticula or crohn,s disease. True stones results from precipitation and deposition of substance from alimentary chime and proximal small bowel enterolith are usually composed of bile acid, while in the distal small bowel are mainly composed of calcium salt.8Hypomotility and stasis are predisposing conditions for enterolith formation and small bowel diverticula are a well known predisposing factor.8,9Hypomotility and stasis may be due to advance age and immobility.We presumed that stone was formed de novo or around a central nidus such as fruit stone or undigested vegetable matter in jejunum in acidic medium, which then moved to ileum where calcification occurred in alkaline medium.

Plain abdominal radiographs are often nonspecific and inconclusive revealing only signs of intestinal obstruction. At times the presence of concomitant pneumobilia may suggest the diagnosis, and only a decade ago, correct pre-operative diagnosis was as low as 20%. However, recent advances in ultrasonography and computerised tomography can show often the Rigler’s triad (pneumobilia, ectopic radio-opaque gallstone and intestinal distension). Presence of two of these radiological signs has been considered sufficient to establish a diagnosis.10

Even though there is universal agreement on surgery as first option treatment for these patients to relieve the intestinal obstruction by removing the stone, there is still reasonable disagreement about the surgical strategy because of low incidence of this disease. In fact, intestinal obstruction requires not a diagnostic approach but rather an emergency surgical treatment and prompt release of intestinal obstruction remains the cornerstoneof management.11

The consensus management of enterolith ileus at laparotomy is to first attempt manual lysis of the stone without enterotomy and to milk the smaller parts in to the colon where they are passed through rectum.12If this is proved to be impossible or inappropriate, the stone is removed through an enterotomy which is made in a less edematous segment of proximal small bowel.

In conclusion, although primary enterolith is a very rare cause of small bowel obstruction, it should be considered in the differential diagnosis when there is no evidence of gall stone ileus,malignancy or stricture. Definitive treatment is surgery and outcome is good if no other comorbid condition is prese

 

Bibliography

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  2. Bruni R, Chiro L, AR,PetroccaS,Intermittent small bowel obstruction by jejunalenteroliths in a patient with a crohns disease stricture.ChirItal 2002;54:903-5.
  3. Singleton JM. Calcific enterolith obstruction of the intestine.Brit J Surg 1970;57:234-6.
  4. Rajenderkumar B, SandhuNS.Jejunal diverticulosis withenterolith-presenting as acute intestinal obstruction.Indian J Surg 2005;67:219-21.
  5. H. K. Mendes Ribeiro and D. J. Nolan, “Enterolithiasis in crohn,s disease,” Abdominal Imaging, vol. 25, no. 5,pp.526-529,2000.
  6. Perez NE, Philips CR, Webber DJ, Guzman CB,Saksouk FA, EhrinpreisMN.Jejunal obstruction caused by a calcified enterolith.PracGastroenterol 2006;30:49-53
  7. Shocket E, Simson SA. Small bowel obstruction due to enterolith formed in a duodenal diverticulum: a case report and review of the literature.Am J Gastroenterol 1982;77:621-4.
  8. Klinger PJ, Seelig MH, Floch NR, Branton SA, Metzger PP. Small intestinal enteroliths: unusual cause of small intestinal obstruction: report of three case. Dis colan Rectum 1999;42:676-9
  9. Lopez PV, Welch JP.Enterolith intestinal obstruction owing to acquired and congenital diverticulosis: report of two case and review of literature. Dis colan rectum 1991;34:941-4
  10. Rigler LG, Borman CM, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestation. JAMA 1941;117:1753-68.
  11. Reisner RM, Cohen JR, Gallstone ileus: a review of 1001 reported cases. Am Surg.1994;60(6):441-446.
  12. Yang HK, Fondacaro PF. Enterolith ileus: A rare complication of duodenal diverticula. Am J Gastroenterol 1992;87:1846-8

 

 

 

AFFILIATIONS – Department of Surgery,

Rajindra Hospital / Government Medical College,

Patiala – 147001

Punjab

Authors 1 – 6 have the same affiliation

CORRESPONDING AUTHOR – Ashwani Kumar

Associate Professor

Department of Surgery

Govt.Medical College and Rajindra Hospital,

Patiala.

E-mail: ashwanicmc@hotmail.com.

CONTACT NO. – +919815504819

FUNDING DETAILS – Self funded

PRESENTATION DETAILS– None

 

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