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SELF ASSESSMENT ANSWERS an Interesting Case of Small Bowel 630 Postgrad Med J 2002;78:630–634 Postgrad Med J: first published as 10.1136/pmj.78.924.633 on 1 October 2002. Downloaded from 6 Shocket E, Simon SA. Small bowel obstuction SELF ASSESSMENT ANSWERS due to enterolith (bezoar formed in a duodenal diverticulum: a case report and review of the literature). Am J Gastroenterol An interesting case of the stomach or small bowel. Four types have 1982;77:621–4. been described based on their composition: 7 Frazzini VI, English WJ, Bashist B, et al. small bowel obstruction phytobezoars (containing fibre and cellulose), Small bowel obstruction due to phytobezoar formation within Meckel diverticulum: CT Q1: What is the diagnosis? trichobezoar, lactobezoars, and miscellaneous. The last group includes medications (hydro- findings. J Comput Assist Tomogr This is a case of mechanical small bowel 1996;20:390–2. scopic bulk laxatives, cholestyramine, non- 8 Maglinte DDT, Chernish SM, DeWesse R, et obstruction secondary to an enterolith/bezoar absorbable antacids, vitamin C tablets, and the likely source of which is jejunal diverticu- al. Acquired jejuno-ileal diverticular disease: Isocal tube feeds), parasites (Ascaris lumbri- subject review. Radiology 1986;158:577– losis 1–3 coides or roundworm), and synthetic fibre. A 80. Q2 : What is the differential case of carpet fibre bezoar forming at the site 9 Brettner A. Euphrat EJ. Radiological diagnosis? of a stapled intestinal anastamosis in a child significance of primary enterolithiasis. with pica has been described.3 In general, the Radiology 1970;94:283–8. This includes the various intraluminal causes formation of bezoars in the small intestine 10 Blake MP. Mendelson RM. Computed of small bowel obstruction such as: appears to be at sites of stasis such as blind tomography in small bowel obstruction. Australas Radiol 1994;38:298–302. • True foreign bodies: metallic, plastic. loops, tumours, and diverticulae (duodenal, 4–7 11 Burkill GJC, Bell JRG, Healy JC. The utility of • Food bolus. jejunal, and Meckels’). computed tomography in acute small bowel The incidence of acquired jejunal diverticu- obstruction.Clin Radiol 2001;56:350–9. • Gallstones. losis varies from 0.2% to 1.3% on necropsy 8 • Concretions. studies to 2.3% on enteroclysis. It is associ- ated in 33% to 75% of cases with diverticula Iatrogenic groin pain Q3: What are the other possible elsewhere in the gastrointestinal tract. En- Q1: What is the likely clinical teroliths that form in the proximal small complications of the primary disease diagnosis? of the small bowel? bowel contain bile salts and are frequently radiolucent whereas as many as a third of The triad of groin pain, hip flexion, and femo- The possible complications include: those that form in the ileum are radio-opaque ral neuropathy indicates iliopsoas sheath • Diverticulitis because of precipitation of mineral salts in an haemorrhage. This condition occurs in pa- 9 tients with inherited coagulation disorders, • Haemorrhage alkaline environment. The diagnosis is therefore rarely made on particularly haemophilia A, and in patients on • Obstruction: 1. True obstruction due to the preoperative plain abdominal radiograph. oral anticoagulants.12 Spontaneous haemor- enterolith, diverticulitis, adhesions associ- Computed tomography is the modality of rhage occurs deep to the iliacus fascia from ated with inflammation, volvulus about the choice for investigating patients with higher the iliacus or psoas muscles, blood tracking adhesions, and intussuception. 2. Pseudo- grades of small bowel obstruction where early from the retroperitoneal space into the pelvic obstruction or motility disorder. surgical intervention is contemplated.10 There extraperitoneal space. Occasionally massive bleeding can lead to signs of volume deficit. • Malabsorption due to stasis and bacterial is an increasing tendency to utilise computed The iliacus fascia invests the psoas major overgrowth. tomography to help define the cause, severity, and complications of small bowel obstruction and iliacus muscles and continues inferiorly • Fistulae. due to the unreliability of clinical signs to pre- as the posterior wall of the femoral sheath. • Asymptomatic pneumoperitoneum. dict accurately those patients requiring early This explains the association with femoral intervention.11 neuropathy, the nerve lying in the groove • Malignant tumours. This is an unusual cause of small bowel between the iliacus and psoas muscles. The Q4: What are the possible treatment obstruction that needs prompt diagnosis and predilection for the iliacus muscle is unclear. options? operative treatment. Q2: What lesion is shown on the The simplest surgical option for small or Final diagnosis computed tomograms (see p 627)? http://pmj.bmj.com/ crushable enteroliths is to milk them distally Enterolith causing small bowel obstruction. The computed tomograms shows a collection into the caecum and allow them to pass natu- behind the left iliacus muscle which displaces References rally. If this is not possible, the treatment of this anteriorly and separates it from the iliac this condition is an enterotomy to remove the 1 O’Malley JA, Ferucci JT Jr, Goodgame JT Jr. blade. The left iliopsoas muscle appears Medication bezoar: intestinal obstruction by enterolith with or without resection of the enlarged with heterogeneous attenuation in- segment of small bowel involved with diver- an isocal bezoar. Gastrointest Radiol 1981;6:141–4. ternally. ticulosis. Resection may be advocated if the 2 Villamizar E, Mendez M, Bonilla E, et al. diverticulosis is localised, and is recom- Q3: How should this condition be Ascaris lumbricoides infestation as a cause of on September 29, 2021 by guest. Protected copyright. mended for the other forms of obstruction, intestinal obstruction in children: experience managed? haemorrhage, and patients with malabsorp- with 87 cases. J Pediatr Surg 1996;31:201–4 In our patient, warfarin was temporarily tion who do not respond to conservative man- (discussion 204–5). stopped. He was administered vitamin K, and agement. 3 Wang PY, Skarsgard ED, Baker RJ. Carpet thereafter started on heparin. The inter- bezoar obstruction of the small intestine. J national normalised ratio came down from Pediatr Surg 1996;31:1691–3. Discussion 7.2 to 2.0 within 24 hours. The pain resolved. The findings at laparotomy were as follows: 4 Klinger PJ, Seelig MH, Floch NR, et al. Small intestinal enteroliths—unusual cause of small There was some residual non-disabling thigh dilated loops of small bowel seen to mid- intestinal obstruction: report of three cases. Dis weakness at the time of discharge. ileum. Obstruction at this point was due to an Colon Rectum 1999;42:676–9. enterolith with collapsed distal bowel (see fig 5 Lorimer JW, Allen MW, Tao H, et al. Small Discussion 3 in questions (p 626) and fig 1 below). Two bowel carcinoid presenting in association with Haemorrhage into the iliacus and or psoas large jejunal diverticulae 12 and 24 inches a phytobezoar. Can J Surg 1991;34:331–3. muscles is a well recognised complication of from the duodenojejunal flexure seen which overanticoagulation, as well as of haemo- were palpably empty. The gallbladder was philiac disorders. The precise incidence and normal with no palpable gallstones. The initiating mechanism of this condition is enterolith was milked proximally and re- unclear. Two anatomical syndromes have been moved via a longitudinal antimesenteric described. enterotomy which was closed transversely, Spontaneous haemorrhage may commence without resection of the diverticular segment. either in the iliacus muscle, in which case At laparotomy it is essential to rule out the bleeding occurs deep to the iliacus fascia and other causes of enteroliths such as gallstones a femoral neuropathy may coexist. Alterna- (as evidenced by a cholecyst-duodenal/jejunal tively bleeding may commence in the psoas fistula) and to carefully palpate the entire major muscle initially or spread from the length of the small bowel including the diver- iliacus muscle to the psoas. In this case ticulae for further enteroliths. involvement of other components of the lum- Bezoars are masses of solidified organic or bosacral plexus, including the obturator nerve non-biological material commonly found in Figure 1 Enterolith. and the lateral femoral cutaneous nerve of the www.postgradmedj.com Self assessment answers 631 Postgrad Med J: first published as 10.1136/pmj.78.924.633 on 1 October 2002. Downloaded from thigh, is likely. A similar clinical picture may which may be aphthoid, superficial, or deep tion, and dilatation proximal to stenosis, be produced by neoplastic infiltration of the are seen surrounded by normal mucosa. thickening of the mucosal folds, cobbleston- lumbosacral plexus. Tuberculoid granuloma is the most specific ing, discrete ulcers, or mural thickening. Long Pain is the presenting feature, involving the finding on histology apart from infiltration of segmental narrowing of the terminal ileum groin, and radiating to the thigh and leg. This lamina propria by lymphocytes and plasma was the only positive finding in the present is followed by gradually increasing paraesthe- cells with aggretates of lymphocytes near the case. siae and limb weakness. A flexion and lateral base of the crypts. In the present case, the Khwaja and Subbuswamy reported ischae- smooth and featureless mucosa, and inflam- mic strictures of the small intestine from rotation deformity of the hip may ensue. Pas- 4 sive hip extension is restricted and painful. matory cellular infiltrate of lamina propria northern
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