Complicated jejunal diverticulitis with small bowel obstruction due to enterolith: A case report

INTRODUCTION AND IMPORTANCE

Small bowel diverticular disease (DD) is encountered and managed much less frequently than colonic DD, leading to a significantly less developed body of evidence for managing small bowel diverticulum and its associated complications.

CASE PRESENTATION

This case report discusses a rare occurrence of simultaneous perforated jejunal diverticulitis and mechanical small bowel obstruction (SBO) due to a migrating diverticular enterolith. The patient's condition was ultimately managed operatively through laparoscopically assisted small bowel resection.

CLINICAL DISCUSSION

A review of the literature reveals only eight reported cases of jejunal diverticulitis with simultaneous enterolith obstruction. All cases were managed operatively, with approaches including small bowel resection encompassing both pathologies, milking the enterolith back to the diverticulitis site and resecting en bloc to avoid extensive resection, or enterotomy and enterolith retrieval.

CONCLUSION

The prevalence of small bowel diverticular disease is increasing, and as a result, clinicians may encounter more complications associated with this condition in the future. This case highlights the importance of considering alternate complications of small bowel DD.

Enterolith at the ileocecal valve mimicking a subepithelial mass

A 32-year-old woman presented with chronic constipation for three years. Colonoscopy revealed a 2.5 cm subepithelial tumor-like lesion at the ileocecal (IC) valve with protrusion of the lesion into the lumen. A CT scan of the abdomen showed an oval-shape laminated calcified lesion adhered to the IC valve and several gallstones. An exploratory laparotomy to enterotomy with stone extraction and open cholecystectomy was performed. Operative findings showed stone erosion into the ileal wall with the lesion being covered with colonic mucosa. Pathologic examination of stones from the intestinal wall revealed an enterolith. The case exemplifies the infrequent cause of a subepithelial lesion of the gastrointestinal tract and a rare presentation of an enterolith as a subepithelial lesion within the terminal ileal wall.

A case of perforation of Meckel's diverticulum with enterolith

Background

Perforation of Meckel’s diverticulum with enteroliths is a rare complication. Here, we report a case of perforation of Meckel’s diverticulum with one enterolith, which could not be accurately diagnosed by preoperative computed tomography.

Case presentation

A 16-year-old male patient with acute onset of severe abdominal pain and a localized muscle guarding in the right hypochondrium had a solitary stone detected in the right abdomen by radiography. Abdominal computed tomography revealed a saclike outpouching of the small intestine, which contained fluid levels and an enterolith, with a mesenteric inflammatory change in the right paraumbilical area. He was diagnosed with peritonitis due to appendicitis or Meckel’s diverticulitis with enterolith, and emergency operation was indicated. The perforated Meckel’s diverticulum was identified approximately 30 cm proximal to the ileocecal valve. The diverticulum was transected at the base and removed. The patient’s postoperative course was uneventful.

Conclusions

It is crucial for clinicians to thoroughly examine patients and appropriately request investigations that consider perforation of Meckel’s diverticulum as a possible diagnosis to facilitate prompt treatment.

Afferent loop obstruction with obstructive jaundice and ileus due to an enterolith after distal gastrectomy: A case report

INTRODUCTION

Afferent loop obstruction is an uncommon complication associated with Billroth II reconstruction or Roux-en-Y reconstruction after gastrectomy. Moreover, cases where the obstruction is caused by enterolith are rare. Here, we report a rare case of afferent loop obstruction caused by an enterolith after Roux-en-Y reconstruction of gastrectomy; subsequently, leading to ileus in the ileum.

PRESENTATION OF CASE

An 84-year-old man who received a Roux-en-Y distal gastrectomy for gastric cancer presented with symptoms of fever and jaundice 14 months later. Computed tomography (CT) scan revealed an enterolith in the duodenal afferent loop and a dilated intrahepatic bile duct. Although the obstructive jaundice and fever disappeared with conservative therapy, ileus occurred due to the movement of the enterolith into the ileum, which was refractory to conservative therapy. Therefore, enterotomy was performed to remove the enterolith, and the patient had an uneventful recovery. Histologically, the enterolith derived from food residue. No postsurgical sign of recurrence has been noted for 6 months.

CONCLUSION

We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the ileum.

A Primary Jejunal Enterolith Presenting as Small Bowel Obstruction

An elderly male presented to our emergency room with acute abdomen. Clinical and imaging evaluations suggested small bowel obstruction due to primary jejunal enterolith with associated stricture. We performed surgical exploration when initial nonoperative therapeutic management failed to resolve the symptoms. Primary jejunal enterolith obstruction is a rare disease presentation reported in literature.

Small Bowel Obstruction Due to Enterolith in a Patient with Diffuse Jejuno-Ileal Diverticulosis

We report an unusual case of small bowel obstruction caused by a large enterolith released from small bowel diverticulitis in a 81-year-old patient with occult massive Diffuse Jejuno-Ileal Diverticulosis (DJID). DJID is a rare condition whose symptoms are usually absent or non-specific. In most cases, the diagnosis of DJID is incidentally made or consecutive to secondary complications comprising obstruction, haemorrhage, diverticulitis and perforation. We shortly review the clinical and imaging features and complications of DJID.

Trace elements in struvite equine enteroliths: Concentration, speciation and influence of diet

Equine enteroliths ∼1.5cm in diameter were collected from an Arabian horse in Louisville, Kentucky, United States. Scanning electron microscopy (SEM) and light microscope imaging of a sectioned enterolith showed two distinct regions of concentric growth outward from the central nidus, a small pebble. After initial growth, acidic colonic fluids permeated the stone inducing recrystallization and alteration of crystals closest to the nidus. A second growth event, when mineral crystallization was again favorable, produced an outer region of unaltered crystals at the rim. The mineral was identified as struvite (MgNH₄PO₄∙6H₂O) by powder X-ray diffraction (XRD) and Fourier transform infrared (FTIR) spectroscopy. Elemental analysis confirmed concentrations of P, Mg and N consistent with the struvite composition, and detected trace elements Fe (1050-1860mgkg^-1), Mn (262-280mgkg^-1) and Zn (197-238mgkg^-1). All elements were traced to dietary sources, with the Fe:Mn:Zn ratio of the enterolith consistent with that of the horse feed. X-ray absorption fine structure (XAFS) spectroscopy at the Zn K-edge revealed distorted ZnO₄ tetrahedra located between crystallographic planes in the struvite structure forming bidentate linkages to struvite phosphate groups. Emplacement of Zn in structural cavities likely occurs during struvite crystallization. Trace elements and organic impurities increase susceptibility of the enterolith to heat-induced decomposition relative to pure struvite, which could be a consideration for treatment. Results reveal enterolith growth processes, composition and mechanisms of trace metal accumulation that can inform management and prevention of equine enteroliths.

Juxtapapillary Duodenal Diverticulum Impacted with Enterolith

A 64-year-old man underwent abdominal computed tomography (CT) as periodic follow-up following a distal gastrectomy with lymphadenectomy for gastric cancer and mucosal-associated lymphoid tissue (MALT) lymphoma conducted 31 months earlier. Contrast-enhanced CT demonstrated a well-circumscribed mass lesion with heterogeneous density measuring 2.2 cm in diameter located between the second segment of the duodenum and uncinate process of the pancreas. Esophagogastroduodenoscopy revealed no remarkable findings in the remnant stomach; however, the scope could not reach the duodenum due to altered anatomy by Roux-en-Y reconstruction after the distal gastrectomy. The patient underwent surgical resection of the mass lesion under the clinical diagnosis of MALT lymphoma relapse. An orange calculus was apparent in the thinly extended duodenal wall on stretching, and the hall was closed by meticulous primary suture after the duodenal resection. Macroscopically, the extracted calculus was solid and quite hard, measured 2.2 × 2.1 × 2.1 cm, and the cut surface revealed a layered structure in the outer areas with granulated contents in the center. Although duodenal diverticula are relatively common, an enterolith developing within a juxtapapillary duodenal diverticulum is rare, and to the best of our knowledge, this is the first such case due to altered anatomy after gastrectomy reported in the English literature.

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.

Common Bile Duct Obstruction Due to a Large Stone at the Duodenal Stump

Enterolith is a rare complication of Billroth II gastrectomy. Most enterolith cases have been reported in association with diverticula, tuberculosis, and Crohn's disease. We report the case of a huge enterolith that developed in the duodenal stump following common bile duct obstruction and cholangitis, necessitating surgery. The enterolith was clearly visible on the abdominal computed tomography. It was removed through a duodenotomy. The surgery was successful without any significant complications.

Intussusception caused by an enterolith from a jejunal diverticulum

We are reporting a case of intestinal obstruction in a lady patient and peroperatively, it turned out to be a case of intestinal obstruction due to intussusception caused by an enterolith originating from one of multiple jejunal diverticula. It was a rare cause of intestinal obstruction, and the presentation was very rare in the literature. The diagnosis and management are thus delayed.

Electrohydraulic lithotripsy of an impacted enterolith causing acute afferent loop syndrome

Afferent loop syndrome caused by an impacted enterolith is very rare, and endoscopic removal of the enterolith may be difficult if a stricture is present or the normal anatomy has been altered. Electrohydraulic lithotripsy is commonly used for endoscopic fragmentation of biliary and pancreatic duct stones. A 64-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy presented with acute, severe abdominal pain for a duration of 2 hours. Initially, he was diagnosed with acute pancreatitis because of an elevated amylase level and pain, but was finally diagnosed with acute afferent loop syndrome when an impacted enterolith was identified by computed tomography. We successfully removed the enterolith using direct electrohydraulic lithotripsy conducted using a transparent cap-fitted endoscope without complications. We found that this procedure was therapeutically beneficial.

Lemmel's syndrome, an unusual cause of abdominal pain and jaundice by impacted intradiverticular enterolith: case report

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.

Perforation of Meckel's diverticulum with enteroliths

Perforation of Meckel's diverticulum with enteroliths is a rare complication. Here, we report a case of perforation of Meckel's diverticulum with enteroliths, which could be accurately diagnosed by the preoperative computed tomography (CT). A 46-year-old man with acute onset of severe abdominal pain, and a localized muscle guarding in the right hypochondrium, had a solitary stone detected in the right abdomen by the radiography. The abdominal CT revealed a saclike outpouching of the small intestine, containing air/fluid levels and an enterolith, with surrounding free air and mesenteric inflammatory change in the right paraumbilical area. He was diagnosed as the perforation of Meckel's diverticulum with enterolith, and the emergency operation was indicated. The perforated Meckel's diverticulum was identified approximately 90 cm proximal to the ileocecal valve. The diverticulum was transected at the base, and removed. The patient's postoperative course was uneventful. This case strongly suggested the ability of CT enterography to accurately diagnose pathologies involving the small intestine, such as the perforation of Meckel's diverticulum, which open premises for its use in the diagnosis of acute abdomen preoperatively.

Large enterolith in a meckels diverticulum causing perforation and bowel obstruction: an interesting case with review of literature

Enteroliths are a rare complication of Meckel's diverticula, with perforation of the diverticulum being an even rarer occurrence. Bowel obstruction secondary to a Meckel's enterolith, albeit uncommon, occurs due to inflammation, intussusception, or impaction after extrusion from the diverticulum. We report an unusual case of Meckel's enterolithiasis causing perforation and bowel obstruction.

Enterolith containing uric Acid: an unusual cause of intestinal obstruction. Indian J Surg. 2011;73:295-297. [PMID: 22851845 DOI: 10.1007/s12262-011-0262-1]

Enterolith is a rare clinical entity that may be found on imaging or at surgery. We report an unusual case of intestinal obstruction caused by a large uric acid containing enterolith which was formed in the absence of any bowel inflammation, stricture or diverticulum.

Jejunal diverticular disease complicated by enteroliths: Report of two different presentations

Jejunal diverticula are quite rare. Furthermore, small bowel diverticular disease resulting in enteroliths can lead to complications necessitating surgical intervention. In this manuscript, we report two presentations of jejunal diverticulum with complications from enteroliths followed by a review of the literature. The first case was that of a 79-year-old male who presented with abdominal pain and was found, on computed tomography (CT) scan, to have evidence of intestinal perforation. A laparotomy showed that he had perforated jejunal diverticulitis. The second case was that of an 89-year-old female who presented with recurrent episodes of bowel obstruction. A laparotomy showed that she had an enterolith impacted in her jejunum in the presence of significant diverticular disease. Although a rare entity, familiarity with jejunal diverticular disease, its complications, and its management, should be part of every surgeon’s base of knowledge when considering abdominal pathology.

Jejunal diverticulosis is not always a silent spectator: A report of 4 cases and review of the literature

Jejunal diverticulosis (JD) is a rare clinical entity. The potential complications of this condition are discussed here through a series of cases presented to our centre. A retrospective analysis of four cases, which were diagnosed and treated, was performed. These included two cases of gastrointestinal haemorrhage, one case of perforation and one case of enterolith obstruction. All of these cases were secondary to jejunal diverticulosis and treated surgically. This was accompanied by a literature search to identify the different modalities for diagnosis and treatment of this condition. JD is rare and may lead to a diagnostic delay. Awareness of the wide spectrum of potential complications can prevent this delay.