- Case study
- Open Access
Subacute intestinal obstruction by enterolith: a case study
© The Author(s) 2016
- Received: 10 June 2016
- Accepted: 24 August 2016
- Published: 31 August 2016
Enteroliths are an uncommon entity in humans and form a rare cause of subacute intestinal obstruction. They occur proximal to stricture or in a diverticulum or a blind loop due to stasis.
40 years male presenting with intermittent right lower abdominal pain since 1 year. Barium meal follow-through and CT abdomen diagnosed as a case of subacute intestinal obstruction with an enterolith in the distal ileal segment. On exploratory laparotomy multiple ileal strictures with mesenteric adhesions were noted. An enterolith was delivered from one of the segments between two strictures followed by segmental resection of the pathological ileal segment with ileo-ileal anastomoses. Histopathology of the ileal segment showed inflammatory infiltrates.
Discussion and Evaluation
It was a case of a primary enterolith formed due to stasis between ileal strictures causing subacute intestinal obstruction.
An enterolith should also be considered while evaluating a case of intestinal obstruction as one of the rare differentials.
- Subacute intestinal obstruction
- Ileo-ileal anastomoses
Subacute intestinal obstruction is a common surgical emergency. Common causes are stricture, polyps and tumours, rarely gall stones or foreign body. Enteroliths are also a cause of intestinal obstruction but are rare. They occur proximal to stricture or in a diverticulum or a blind loop. Stasis is an important factor in their production (Yadav et al. 2015). Enteroliths were first described by Pfahler and Stamm in 1915 (D’souza et al. 2010). Here we present a case of subacute intestinal obstruction with multiple strictures and enterolith in the distal ileum, who underwent segmental ileal resection and ileo-ileal anastomoses.
Patient is asymptomatic after one year of follow-up.
Primary enteroliths are formed in the small bowel and secondary enteroliths are formed in gallbladder as gallstones. (Yadav et al. 2015) True enteroliths of small intestine can be of 3 types depending on their composition—(1) those consisting of mainly bile acids, (2) those consisting of mainly phosphates, (3) those consisting of mainly calcium oxalate (D’souza et al. 2010; Shivathirthan et al. 2009). False endogenous enteroliths are common than true enterolith (Singleton 1970).
The site and pH of the intestinal lumen defines the chemical composition of enteroliths. The relatively high acidity of the proximal duodenum and jejunum allows precipitation of bile acids, particularly cholic acid, which are radiolucent. Precipitation of calcium in the lower distal parts of small intestine due to the alkaline pH in this region promotes formation of radio-opaque enteroliths (Oel-F et al. 2004).
Stasis, either due to stricture formation (intestinal tuberculosis, Crohn’s disease, carcinoid tumor, post-traumatic or post-surgical strictures, radiation enteritis, etc.) or diverticulae form the main reason for enterolith formation (Oel-F et al. 2004). Gamblin et al. (2003) and Jones and McWhirter (2010) reported cases of enterolith formation in Meckles diverticulum. Sureka et al. (2014) reported an interesting case of a radiopaque shadow in the pelvic region which was thought to be a vesical calculus but on further investigation was diagnosed as an enterolith in the ileal loop. In Crohns disease, multiple areas of small bowel stenosis are relatively common, but there are only few reported cases with stenosis complicated by enterolith. Geoghegan et al. (2005) reported a case of small bowel obstruction secondary to a giant enterolith in a patient of Crohn’s disease. Svanes and Halvorsen (1975) and Klinger et al. (1999) reported cases of enteroliths in jejunal diverticulae.
Most enteroliths are in apparent and cause no complications but sometimes may present with complications like intestinal obstruction, ileus or perforation. Klinger et al. (1999) in their article suggested that first therapeutic approach should be nonsurgical and surgery should be considered only if obstruction persists. Surgical management commonly involves enterotomy or occasionally resection.
Strictures can be a cause of stasis causing primary enteroliths and should be considered while evaluating a case of Subacute intestinal obstruction.
VK was the main operating surgeon and AK assisted in the surgery. AK co-ordinated with the various departments for assembling data like Histopathological slides etc. VK and AK together drafted the manuscript. Both authors read and approved the final manuscript.
We extend our sincere gratitude to Dr. R.G. Devani, Professor of surgery for guiding us, Dr. R.B. Dhaded, HOD surgery department, M.R. Medical College for all his support and Dr. S. K. Andola, Professor and HOD pathology Department for his support with the histopathological diagnosis and Dr. Somshekar Solpure, post-graduate in surgery for his assistance in patient management.
The authors declare that they have no competing interests.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
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