Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 1233 


 
Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 17  |  Issue : 6  |  Page : 418-420
Enterolith with enterocolic fistula: The diagnostic approach


1 Department of Surgery, Goa Medical College, Goa, India
2 Department of Radiology, Goa Medical College, Goa, India

Click here for correspondence address and email

Date of Submission29-Nov-2010
Date of Acceptance14-Mar-2011
Date of Web Publication5-Nov-2011
 

   Abstract 

An enterolith is a mixed concretion formed in GIT, usually rare in humans. Primary enteroliths are formed in small bowel, typically within a diverticulum and secondary enteroliths in gallbladder. This case report highlights the presence of an enterocolic fistula; probably a postradiotherapy complication; and an enterolith without associated small bowel or colonic diverticuli. We have discussed the various diagnostic modalities used to reach a preoperative diagnosis of this rare condition. Imaging plays an important role in the detection and management of acquired gastrointestinal fistulas. The more routine use of cross-sectional imaging (especially computed tomography and magnetic resonance imaging) has altered the standard sequence of radiologic evaluation for possible fistulas, but fluoroscopic studies remain a valuable complement, especially for confirming and defining the anomalous communications.

Keywords: Enterolith, enterocolic fistula, imaging modalities

How to cite this article:
Salelkar RS, Patil RT, Amonkar DP, Sardessai SG. Enterolith with enterocolic fistula: The diagnostic approach. Saudi J Gastroenterol 2011;17:418-20

How to cite this URL:
Salelkar RS, Patil RT, Amonkar DP, Sardessai SG. Enterolith with enterocolic fistula: The diagnostic approach. Saudi J Gastroenterol [serial online] 2011 [cited 2019 Jul 15];17:418-20. Available from: http://www.saudijgastro.com/text.asp?2011/17/6/418/87186


An enterolith is a mixed concretion formed in GIT, usually rare in humans. Enteroliths are of endogenous origin and most usually formed from the bile constituents. However, when calcium salts predominate, they form in the distal small bowel. It is suggested that stasis is the most important factor in their production. [1] Herein, we report the presence of a calcified enterolith at the site of an enterocolic fistula. Such an occurrence has not been reported earlier to the best of our knowledge.


   Case Report Top


A 52-year-old female presented with anorexia and abdominal pain since 2 years. Patient gave history of undergoing hysterectomy eight years back, for endometrial carcinoma. Postoperatively radiotherapy was advised; but due to extreme morbidity, she could receive only 10 fractions. Details of this treatment were not available as she was treated at a different hospital. Clinically, the patient's vital organs were stable. On per abdomen examination, a 12 × 10 cm firm mobile lump was palpable in the left lumbar region. Her hemoglobin and counts were normal. Renal functions were also normal. Abdominal USG revealed an echogenic mass, 8 × 7 cm, showing posterior acoustic shadowing, probably inspissated fecal matter. A repeat USG performed 4 days later after giving water enema showed the mass unchanged in size and echotexture. CT scan indicated a mass with peripheral calcification [Figure 1], but was unable to differentiate whether it was in colon or small bowel loops. There was no evidence of any recurrence or metastatic lesion of the endometrial primary. Barium enema revealed an entero-colic fistula with an enterolith at the site of the fistula [Figure 2]. Colonoscopy showed a fistulous opening in region of sigmoid colon. A clinical and radiological diagnosis of enterolith with entero-colic fistula was made. Patient underwent an exploratory laprotomy under general anesthesia after bowel preparation. At laprotomy a fistula between mid-ileum and sigmoid colon was seen, containing a hard nonmobile mass. Rest of the small bowel and colon was normal, no diverticuli were detected. Gall bladder and common bile duct were normal. Segmental enterectomy with sigmoidectomy [Figure 3]
Figure 1: CT scan indicating a mass with peripheral calcification.

Click here to view
Figure 2: Barium enema showing an entero-colic fistula with an enterolith at the site of the fistula

Click here to view
Figure 3: Segmental enterectomy with sigmoidectomy specimen with enterolith

Click here to view


was done and patient had an uneventful recovery. Cut-section of the specimen showed presence of an enterolith obliterating the lumen of the fistulous connection between the two bowel loops. The mucosa appeared normal. Histopathology was unremarkable, showing congestion and acute on chronic inflammation. The presence of enlarged nuclei was the only change that could be attributed to radiotherapy. Chemical analysis of the enterolith revealed calcium carbonate in a matrix of amorphous material.


   Discussion Top


An enterolith is a mixed concretion formed in GIT, usually rare in humans. Enteroliths are divided into two groups: false enteroliths and true enteroliths. False enteroliths are common than true. They develop, often in presence of stasis by clumping together and inspissation of intestinal contents. They form around a nidus, usually a foreign body, which acts as an irritant. True enteroliths result from precipitation and deposition of substances normally found in solution in the gastrointestinal tract. [1] Proximal small bowel enteroliths are usually composed of bile acids whereas distal small bowel (ileal) enteroliths contain calcium. It is postulated that diverticuli provide the more acidic environment necessary for choleic acid precipitation and stone formation. [2] However, calcification cannot occur without an alkaline pH shift, which normally occurs in the ileum, [3] and hence, enteroliths in the distal small bowel are mainly composed of calcium salts which are less soluble in alkali and, therefore, tend to be precipitated in the distal small intestine. [4]

Primary enteroliths are formed in small bowel, typically within a diverticulum and secondary enteroliths are formed in gallbladder, [1] which reach the small bowel due to choledochoenteric fistulas. Most enteroliths are asymptomatic. Complications, if any, are likely to be severe such as obstruction, [5] ileus, [6] and perforation. Therapeutic approach is to crush and milk the enterolith down to colon. If this fails, Enterotomy with extraction or segmental resection of bowel are other options. [6] In this patient, the gall bladder and the common bile duct were normal and, hence, the enterolith was a primary enterolith. As mentioned earlier, primary enteroliths are usually associated with small bowel diverticuli and the absence of small bowel or colonic diverticuli in this patient makes this case unusual. This case report highlights the presence of an enterocolic fistula with an enterolith; an occurrence which has not been reported earlier.

This enterocolic fistula was probably a postradiotherapy complication. The patient had undergone hysterectomy and this pelvic surgery may be the reason for the ileal loop getting adherent to the sigmoid colon and thus exposed in the radiation portal. Fistula formation, along with bowel obstruction and perforation, are late complications of radiotherapy and are thought to be secondary effects of radiation-induced endarteritis and diffuse collagen deposition. [7] The H-shaped enterocolic fistula acted like a side to side enteric anastomosis and the outpouching caused pooling of intestinal contents. Thus, the relative stasis at the fistula site coupled with the alkaline pH medium in the ileum probably led to precipitation of this calcium containing enterolith. Diarrhea, with or without abdominal pain, is the most common symptom of intestinal fistulae. [8] This patient, however, was relatively asymptomatic for the fistula because of the presence of the enterolith which obliterated the lumen of the fistula. In this case, the sequential use of cross-sectional imaging and contrast imaging helped in diagnosing the fistula as well as the presence of the enterolith. Cross-sectional imaging, particularly computed tomography (CT), has strengthened the radiologist's armamentarium for evaluating GI fistulas. CT effectively complements conventional radiography with its ability to demonstrate extraluminal disease, including associated abscesses, tumor, or other coexisting processes. In this patient, CT helped to detect the enterolith and also ruled out any recurrence of the primary pelvic malignancy. Although CT may be less sensitive for direct detection of some GI fistulas, it often yields more valuable information overall with respect to patient care.


   Conclusion Top


When evaluating abdominal complaints in patients treated with pelvic surgery and radiotherapy in the past, delayed complications of radiotherapy such as fistula formation and intestinal obstruction should be ruled out. Enterolith formation at the fistula is a rare complication, not described earlier, and sequential use of diagnostic modalities helped in reaching a diagnosis. In general, contrast-enhanced fluoroscopic GI studies remain the most effective means for help in diagnosing intestinal fistulas. [8] Furthermore, it is important to at least consider the need for obtaining a CT scan prior to performing a conventional barium examination, because residual barium can produce troubling artifacts on CT.

 
   References Top

1.Singleton JM. Calcific enterolith obstruction of the intestine. Br J Surg 1970;57:234-6.  Back to cited text no. 1
[PUBMED]    
2.Shocket E, Simon SA. Small bowel obstruction due to enterolith (bezoar) formed in a duodenal diverticulum: A case report and review of the literature. Am J Gastroenterol 1982;77:621-4.  Back to cited text no. 2
[PUBMED]    
3.Hayee B, Khan HN, Al-Mishlab T, McPartlin JF. A case of enterolith small bowel obstruction and jejunal diveticulosis. World J Gastroenterol 2003;9:883-4.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Crane PW, Crocker PR, Levison DA, Gilmore OJ. Enterolith ileus. J R Soc Med 1988;81:2924.  Back to cited text no. 4
    
5.Gamlin TC, Glenn J, Herring D, Mckinney WB. Bowel obstruction caused by a meckels diverticulum enterolith: A case report and review of literature. Current Surg 2003;60:63-4.  Back to cited text no. 5
    
6.Steenvoorde P, Schaardenburgh P, Viersma JH. Enterolith ileus as a complication of jejunal diverticulosis: Two case reports and a review of literature. Dig Surg 2003:20:57-60.  Back to cited text no. 6
    
7.Cheung CP, Chiu HS, Chung CH. Small bowel perforation after radiotherapy for cervical carcinoma. Hong Kong Med J 2003;9:461-3.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Pickardt PJ, Bhalla S, Balfe M. Acquired gastrointestinal fistulas: Classification, Etiologies and imaging evaluation. Radiology 2002;224:9-23.  Back to cited text no. 8
    

Top
Correspondence Address:
Reshama S Salelkar
Qtr. No. 6, Type 5 GMC Qtrs., Opp. SBI Bambolim Branch, GMC Staff Qtrs., Bambolim, Goa 403 202
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.87186

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Enterolitiasis no obstructiva: presentación de 2 casos
Miguel Ruiz Marín,M. Encarnación Tamayo Rodríguez,Francisco Miguel González Valverde,Marcelino Méndez Martínez,Ángela Sánchez Cifuentes,María Maestre Maderuelo,Antonio Albarracín Marín Blázquez
Gastroenterología y Hepatología. 2012; 35(4): 247
[Pubmed] | [DOI]
2 Non-obstructive enterolithiasis: Report of two cases [Enterolitiasis no obstructiva: Presentación de 2 casos]
Ruiz Marín, M. and Tamayo Rodríguez, M.E. and González Valverde, F.M. and Méndez Martínez, M. and Sánchez Cifuentes, Á. and Maestre Maderuelo, M. and Albarracín Marin Blazquez, A.
Gastroenterologia y Hepatologia. 2012; 35(4): 247-250
[Pubmed]



 

Top
  
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2168    
    Printed100    
    Emailed0    
    PDF Downloaded231    
    Comments [Add]    
    Cited by others 2    

Recommend this journal