E200 Cases and Techniques Library (CTL)

similar symptoms recurred 2 years later. A second ileoscopy showed a narrowed Enteroliths in a Kock continent ileostomy: efferent loop that was dilated by insertion case report and review of the literature of the colonoscope, with successful relief of her symptoms. Chemical analysis of one of the retrieved enteroliths revealed calcium oxalate crystals. Five cases have previously been noted in the literature Fig. 1 Schematic (●" Table 1). representation of a Kock continent The alkaline milieu of succus entericus in ileostomy. the ileum may induce the precipitation of a calcium oxalate concretion; in contrast, the acidic milieu found more proximally in the intestine enhances the solubility of calcium. The gradual precipitation of un- conjugated bile salts, calcium oxalate, and

Valve calcium carbonate crystals around a nidus composed of fecal material or undigested Efferent loop fiber can lead to the formation of calcium oxalate calculi over time [5].

Endoscopy_UCTN_Code_CCL_1AD_2AJ Reservoir Competing interests: None

Hadi Moattar1, Jakob Begun1,2, Timothy Florin1,2 1 Department of Gastroenterology, Mater Adult Hospital, South Brisbane, Australia The Kock continent ileostomy (KCI) was dure was done to treat ulcerative pan- 2 Mater Research, University of Queens- designed by Nik Kock, who used an intus- colitis complicated by colon cancer. She land, Translational Research Institute, suscepted ileostomy loop to create a nip- had a well-functioning KCI that she had Woolloongabba, Australia ple valve (●" Fig.1) that would not leak catheterized daily for 34 years before she and would allow ileal effluent to be evac- presented with intermittent abdominal uated with a catheter [1]. Enterolith for- pain and occasional bleeding from the References mation is a rarely reported long-term stoma, and she reported having difficulty 1 Kock NG. Intra-abdominal “reservoir” in pa- tients with permanent ileostomy. Prelim- complication of KCI that can lead to dis- catheterizing her ileostomy. inary observations on a procedure resulting abling symptoms mandating treatment Computed tomography and ileoscopy in fecal “continence” in five ileostomy pa- [2–4]. demonstrated three oval enteroliths in tients. Arch Surg 1969; 99: 223–231 We report the case of a 65-year-old wom- the pouch and a lipoma in the efferent 2 Baig MK, Valerian B, Hakim L et al. Holmium: an who underwent total proctocolectomy loop of the KCI (●" Fig.2). The patient’s yttrium aluminium garnet laser lithotripsy for symptomatic Kock pouch calculi. Surg and subsequent construction of a KCI symptoms decreased after resection of Innov 2006; 13: 193–197 when she was 31 years of age. The proce- the lipoma with a snare cautery. However, This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Fig. 2 a Abdominal computed tomographic scan demonstrating enteroliths in the Kock continent ileostomy (KCI) (arrow). b Polypoid lesion in the efferent loop of the KCI (arrow). c Darkly pigmented enteroliths in the KCI (arrow).

Moattar Hadi et al. Enteroliths in a Kock continent ileostomy… Endoscopy 2015; 47: E200–E201 Cases and Techniques Library (CTL) E201

Table1 Reported cases of enterolith associated with Kock continent ileostomy (KCI).

Patient Time Presenting symptoms Diagnostic modalities Composition of stones Treatment and outcome Source gender with Number of stones, and age, KCI, n y y

Female, 48 23 Abdominal pain, Abdominal X-ray, Calcium oxalate, 95 % Symptomatic relief after Baig et al. [2] frequent need for pouch ileoscopy Calcium phosphate, 5 % endoscopic stone extrac- catheterization 3 tion following holmium- yttrium-aluminum garnet laser lithotripsy Female, 39 9 Increased pouch output, Abdominal X-ray, Calcium hydroxyapatite Symptom resolution after Fox et al. [3] abdominal cramps, barium study, ileoscopy surgical exploration and weight loss 15 stone removal Female, 53 20 Abdominal pain, Abdominal X-ray, Cholesterol, 50 % Endoscopic extraction of Geller et al. [4] blood in pouch contents ileoscopy Other unidentified lipid, enteroliths with basket, 30 50 % outcome not specified Male, 52 15 Abdominal pain, Ileoscopy Not specified Patient declined further Geller et al. [4] blood in pouch contents 12 intervention Female, 55 13 Abdominal pain, Ileoscopy Not specified Unsuccessful endoscopic Geller et al. [4] peristomal itching and 8 extraction with snare and erythema lithotripsy basket, patient declined further interven- tion Female, 65 34 Abdominal pain, Abdominal computed Calcium oxalate, 90 % Symptomatic improve- Current case difficulty catheterizing tomography, ileoscopy Calcium phosphate, 10 % ment after efferent loop pouch, bleeding from stoma 4 stricture relieved with resection of a lipoma and dilation

3 Fox ER, Chung T, Laufer I. Enteroliths in a Bibliography Corresponding author continent ileostomy. AJR Am J Roentgenol DOI http://dx.doi.org/ Hadi Moattar, MD 1988; 150: 105–106 10.1055/s-0034-1391302 Department of Gastroenterology 4 Geller A, Clain JE, Lewis BS et al. Enteroliths Endoscopy 2015; 47: E200–E201 Mater Adult Hospital in a Kock continent ileostomy: endoscopic © Georg Thieme Verlag KG Raymoond Terrace South Brisbane diagnosis and management. Gastrointest Stuttgart · New York Brisbane, Queensland 4101 Endosc 1998; 48: 306–308 ISSN 0013-726X Australia 5 Paige ML, Ghahremani GG, Brosnan JJ. Lami- Fax: +617 3163 8548 nated radiopaque enteroliths: diagnostic [email protected] clues to intestinal pathology. Am J Gastro- enterol 1987; 82: 432–437 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Moattar Hadi et al. Enteroliths in a Kock continent ileostomy… Endoscopy 2015; 47: E200–E201