Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 10  |  Issue : 2  |  Page : 96-98
Enterolithiasis


Department of Surgery, King Khalid University Hospital Riyadh, Saudi Arabia

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Date of Submission22-Mar-2003
Date of Acceptance18-Oct-2003
 

How to cite this article:
El-Tinay OE, Guraya SY, Noreldin O. Enterolithiasis. Saudi J Gastroenterol 2004;10:96-8

How to cite this URL:
El-Tinay OE, Guraya SY, Noreldin O. Enterolithiasis. Saudi J Gastroenterol [serial online] 2004 [cited 2019 Nov 12];10:96-8. Available from: http://www.saudijgastro.com/text.asp?2004/10/2/96/33343


Enterolithiasis is an uncommon cause of vague abdominal pain, intestinal obstruction or perforation [1] . Primary small bowel stones with calcific foci can be an incidental finding on plain abdominal x­ray [2] . Such stones may remain silent or manifest with enterolith-induced bleeding, diverticulitis or internal fistula [3] . We report a case of enterolithiasis to emphasize the importance of this clinical entity and to highlight its varied presentations.


   Case Report Top


A 70-year-old Saudi male was admitted electively with complaint of central abdominal pain of six-day duration. The pain was of moderate intensity, non­radiating and exacerbated by food intake. His past medical profile was not suggestive of any associated medical condition and there was no history of use of herbal medications or excessive intake of tea or coffee. Initially, the patient used analgesia but later on the severity of pain prompted him to seek medical advice. On examination the patient looked well with normal vital signs. Abdominal examination revealed a soft, lax abdomen with a firm and non tender mass in the right iliac fossa measuring about 6x6cm. The mass was not adherent to the surrounding structures and bowel sounds were audible with normal frequency. The rest of the systemic review was unremarkable. Baseline blood investigations, chest x-ray and ECG were normal. Ultrasound of the abdomen showed fatty infiltration of the liver and multiple calculi in the gall bladder. CT scan of the abdomen confirmed the presence of gallstones and demonstrated markedly dilated distal ileum with multiple lamellated filling defects noticed within the bowel lumen. The patient was subjected to exploratory laparotomy through a midline incision. There was grossly dilated proximal small bowel with a diverticulum at the mid ileum measuring about 7x7cm, which contained at least six stones [Figure - 1]. There were significant adhesions between the gall bladder, omentum and adjacent parts of the duodenum and transverse colon [Figure - 2]. Cholecystectomy was performed after breaking down all the adhesions. No fistulous communication could be demonstrated with the intra-operative cholangiogram. Resection and anastomosis of the small bowel containing stones was then carried out using the stapling technique. The resected specimen was sent for histopathological examination [Figure - 3]. Abdomen was drained and closed in layers. The pathology report of the small bowel containing diverticulum revealed chronic inflammation and fibrosis with formation of foreign body giant cell reaction in the bowel mucosa while there was evidence of chronic cholecystitis in the gall bladder specimen, which contained multiple stones. The biochemical analysis of the stones retrieved from the bowel showed the presence of calcium and oxalate crystals along with concretions of ingested vegetable fiber. Calcium oxalate was reported to be the major component of these stones. On the other hand, the gallstones were found to be composed of calcium bilirubinate. The patient had uneventful recovery and was discharged home on the 8th postoperative day.


   Discussion Top


Enterolithiasis is a rarely encountered clinical and radiological entity [3] . The clinical setting varies as widely as does the radiological differential diagnosis. Stasis of the intestinal contents is the underlying cause of stone formation. Enterolithiasis may be asymptomatic or symptomatics. Symptoms include bleeding, diverticulitis, intestinal obstruction or abdominal pain [4] . Although enterolithiasis is occasionally associated with intestinal obstruction, the clinical presentation may be dominated by perforation [5],[6],[7] . In our patient, a vague abdominal pain was the leading complaint. Calcified enteroliths are an infrequent variant of small bowel stones caused by stasis of intestinal contents due to Meckel's diverticulum, Crohn's disease or abdominal tuberculosis [8] . Paige et al have published a series of 14 cases with enterolithiasis; 12 patients had stones in the small bowel and two had stones in the colon proximal to strictures, complicating ulcerative colitis [9] . An enterolith had been reported in the prestenotic saccular dilatation from a post operative stricture of the terminal ileum [10] . The present report substantiates the finding that stasis has been the initiating factor in the development of enteroliths. Subsequently, the enteroliths triggered the development of a false ileal diverticulum with its associated foreign body giant cell reaction. Our case report is ih agreement with the general consensus that resection and anastomosis of the involved bowel with enterolithiasis provides adequate surgical relief [11],[12] . The chemical composition of the enteroliths ruled out the clinical possibility of gallstone ileus.

To conclude, enterolithiasis should be a diagnostic consideration in patients presenting with nonspecific abdominal pain or intestinal obstruction. Stasis of the intestinal contents predisposes to the formation of enteroliths and resection of the involved bowel segment is attended with favorable results.

 
   References Top

1.Pouillaude JM, Meyer P, Tran V, Dodat H,Valla JS. Enterolithiasis in two neonates with oesophageal and anorectal atresia. Paediatr Radiol 1987; 17: 419-21.  Back to cited text no. 1    
2.Gupta NM, Pijla RK, Talwar BL. Calcific enterolithiasis. Indian J Gastroenterol 1986; 5: 29-30.  Back to cited text no. 2    
3.Javors BR, Bryk D. Enterolithiasis: a report of four cases. Gastrointest-Radiol 1983; 8: 359-62.  Back to cited text no. 3  [PUBMED]  
4.Khan A, Schreiber S, Berkelhammer C. Enteroliths-induced perforation in small bowel carcinoid tumor. Am J Gastroenterol 2001; 96: 261.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Yuan JG, Sachar DB, Kaganei K, et al. Enterolithiasis, refrectory anemia and strictures of Crohn's disease. J Clin Gastroenterol 1994; 18: 105-8.  Back to cited text no. 5    
6.Salim AS. Small bowel obstruction with multiple perforations due to enterolith (bezoar) formed without gastrointestinal pathology. Postgrad Med J 1990; 66: 872-3.  Back to cited text no. 6  [PUBMED]  
7.Zeit RM. Enterolithiasis associated with ileal perforation in Crohn's disease. Am J Gastroenterol 1979; 72: 662-4.  Back to cited text no. 7  [PUBMED]  
8.Chawla S, Bery K, Indra KJ. Enterolithiasis complicating intestinal tuberculosis. Clin Radio] 1966; 17: 274-9.  Back to cited text no. 8    
9.Paige ML, Ghahremani GG, Brosnan JJ. Laminated radiopaque enteroliths: diagnostic clues to intestinal pathology. Am J Gastroenterol 1987; 82: 432-7.  Back to cited text no. 9  [PUBMED]  
10.Lantsberg L, Eyal A,Khodadadi J, Hirsch M . Enterolithiasis. J Clin Gastroenterol 1988; 10: 165-8.  Back to cited text no. 10    
11.Van der Bruggen, Pieterman H. Enterolithiasis in a patient with Meckel's diverticulum and Crohn's disease. ROFO Fortschr-Geb­Nuklearmed 1988; 149: 552-3.  Back to cited text no. 11    
12.Lorimer JW, Allen MW, Tao, et al. Small bowel carcinoid presenting in association with phytobezoar. Can J Surg 1991; 34: 331-3.  Back to cited text no. 12    

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Correspondence Address:
Omer El-Faroug El-Tinay
Department of Surgery, College of Medicine and King Khalid University Hospital PO Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861833

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