Small bowel obstruction secondary to a giant enterolith complicating Crohn's disease

An Unusual Presentation of Crohn's Disease Diagnosed Following Accidental Ingestion of Fruit Pits: Report of Two Cases and Review of the Literature

The clinical course of Crohn’s disease (CD) is often complicated by intestinal strictures, which can be fibrotic, inflammatory, or mixed, therefore leading to stenosis and eventually symptomatic obstruction. We report two cases of subclinical CD diagnosed after fruit pit ingestion, causing bowel obstruction; additionally, we conducted a narrative review of the scientific literature on cases of intestinal obstruction secondary to impacted bezoars due to fruit pits. Symptoms of gastrointestinal bezoars in CD patients are not diagnostic; and the diagnosis should be based on a combined assessment of history, clinical presentation, imaging examination and endoscopy findings. This report corroborates the concept that CD patients are at a greater risk of bowel obstruction with bezoars generally and shows that accidental ingestion of fruit pits may lead to an unusual presentation of the disease. Therapeutic options in this group of patients differ from the usual approaches implemented in other patients with strictures secondary to CD.

Subacute intestinal obstruction by enterolith: a case study

Introduction

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.

Case description

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.

Conclusion

An enterolith should also be considered while evaluating a case of intestinal obstruction as one of the rare differentials.

Small-bowel obstruction associated with Crohn's enterolith

One of the lesser known clinical manifestations of Crohn's disease is the formation of small-bowel enteroliths. These concretions precipitate in the setting of small-bowel stasis within the alimentary tract and are associated with a variety of disease states causing strictures or diverticula. In the acute setting, patients typically present with signs of intestinal obstruction due to stone impaction. The case we report involves a 67-year-old female with long-standing Crohn's disease who presented with a 6-day history of worsening abdominal pain. Plain abdominal radiographs demonstrated dilated bowel loops consistent with intestinal obstruction. Computed tomography revealed a 2.5-cm calcified density at the transition point in the distal ileum, and two additional stones were present in the proximal ileum. At surgery, multiple ileal strictures were found, and ileocolic resection with primary anastomoses was performed. The accurate diagnosis of enterolithiasis in the setting of Crohn's disease has significant clinical implications for management and is a harbinger of underlying bowel stenosis.

The patient with recurrent (sub) obstruction due to Crohn's disease

Stricturing Crohn's disease (CD) occurs in 12-54% of the CD patient population and is associated with significant morbidity and impaired quality of life. The detailed pathophysiology of stricture formation has not been fully elucidated, but is primarily associated with luminal narrowing secondary to inflammation and the fibrosis that ensues during mucosal healing. The diagnosis of stricturing disease is based on clinical signs and symptoms along with imaging modalities. The advantages and shortcomings of each imaging modality are discussed. Treatment options are based on the differentiation between inflammatory versus fibrous-predominant strictures; whereas the former can potentially be managed with conservative medical treatment, the latter necessitates a mechanical solution through endoscopy or surgery. Indications, contra-indications and success rates of the different therapeutic approaches are discussed.