A CASE TO REMEMBER

Jejunal Obstruction Caused by a Calcified Enterolith

by Nolan E. Perez, Cherie R. Phillips, John D. Webber, Cristina B. Guzman, Faysal A. Saksouk and Murray N. Ehrinpreis

Nolan E. Perez Murray N. Ehrinpreis

A 98-year-old woman presented with several weeks of nausea, vomiting, abdominal pain and anorexia, and was found to have a persistent small bowel obstruction (SBO). A 4 × 3 cm calcified mass was discovered in the small bowel on computed tomography causing suspicion for gallstone ileus. The diagnosis of a calcified enterolith was made after exploratory laparoscopy given the absence of findings for gallstone ileus and the composition of the large amorphous stone. Small bowel obstruction resulting from stone impaction is very rare, with most cases caused by a gallstone ileus or by an enterolith formed in a small bowel diverticu- lum. We report the second case of proximal SBO caused by a calcified enterolith, but our case is unique due to the absence of small bowel diverticula.

Nolan E. Perez, M.D., Division of Gastroenterology; Cherie R. Phillips, M.A.; John D. Webber, M.D., Department of Surgery; Cristina B. Guzman, M.D., Division of Endocrinology; Faysal A. Saksouk, M.D., Department of Radiology; Murray N. Ehrinpreis, M.D., Division of Gastroen- terology; all at Wayne State University School of Medicine, Detroit, MI.

PRACTICAL GASTROENTEROLOGY • JANUARY 2006 49 Jejunal Obstruction Caused by a Calcified Enterolith A CASE TO REMEMBER

Fig. 1. Calcified mass in the small bowel located in the Fig. 2. Dilated proximal small bowel filled with air and fluid. pelvis.

INTRODUCTION Due to advanced age, previous stroke and dementia, rimary enteroliths are formed in the small bowel she was mostly bedridden and cared for by her family and secondary enteroliths (gallstones) are at home. P formed in the gallbladder (1). In the differential On examination the patient was afebrile and had diagnosis of a small bowel obstruction (SBO) occur- mild tachycardia. The abdomen was distended with ring in the elderly, one should always consider gall- increased bowel sounds and mild tenderness. There stone ileus, which occurs when a gallstone is passed were no hernias. White blood cell count was 13,200 through a biliary-enteric fistula. Gallstone ileus is well cells/cumm and hemoglobin 11.2 g/dL. Electrolytes, described, but there are few reported cases of primary amylase, lipase and liver tests were normal. Computed enteroliths causing SBO. Herein, we report an exceed- tomography (CT) revealed a 4 × 3 cm calcified mass in ingly rare case of a calcified enterolith causing jejunal the small bowel, located in the pelvis, with dilated obstruction without associated small bowel divertic- proximal loops (Figures 1–2). There was no pneumo- ula. This is only the second reported case of a calcified bilia and the gallbladder was normal. On review of primary enterolith causing proximal SBO (2). prior radiographs, the calcified mass was not definitely discernable on the plain films, but it was visible, though overlooked, on a prior CT exam. CASE REPORT The patient was initially treated conservatively with A 98-year-old woman presented with several weeks IV fluids, no oral intake and nasogastric tube suction. of nausea, vomiting, abdominal pain and anorexia. After several days, however, she developed increased This was her third admission in the past month abdominal pain and absent bowel sounds. Exploratory for these complaints. She had a history of diverticulo- laparoscopy was performed. Intra-operatively, a hard sis coli, dementia, arthritis, hypertension, ischemic non-mobile mass was palpated in the distal jejunum stroke and congestive heart failure. Her medications with dilated bowel proximally. The entire small bowel included ciprofloxacin, diltiazem, pantoprazole and was carefully inspected and no diverticula were identi- supplemental nutritional drinks. Her past surgeries fied. There were no hernias and the gallbladder and included an abdominal hernia repair and hysterectomy. (continued on page 52)

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lying, but the surrounding mucosa was normal and there was no underlying stricture or other small bowel pathol- ogy. The stone measured 4.5 × 3 × 3 cm and sectioning revealed multiple layers (Figures 3–4). Stone analysis showed miscellaneous material with an amorphous component containing bilious byproducts. After surgery, her symptoms resolved and she was able to tolerate oral intake. However, due to comor- bidities, advanced age and deconditioning, she had a lengthy hospital stay and was not discharged until 2 weeks later.

DISCUSSION Enteroliths are divided into two groups: false Fig. 3. Intact stone measuring 4.5 × 3 × 3 cm. enteroliths and true enteroliths (3). False enteroliths (i.e. fecoliths, varnish stones, almond pits, fruit skins, oat stones, phytobezoars or trichobezoars, and foreign common bile duct were normal. The mass could not be bodies) are formed by clumping together and inspissa- “milked” in either direction, so approximately 2–3 cm tion of intestinal content (3–5). True enteroliths result of jejunum was resected on either side of the mass. from precipitation and deposition of substances from Pathology results of the resected small bowel revealed alimentary chime (3). Proximal small bowel enteroliths acute mucosal necrosis in the area where the stone was are usually composed of bile acids, while those in the

Fig. 4. Sectioned stone revealing multiple layers.

52 PRACTICAL GASTROENTEROLOGY • JANUARY 2006 Jejunal Obstruction Caused by a Calcified Enterolith

A CASE TO REMEMBER

distal small bowel are mainly composed of calcium malignancy. Definitive treatment for enterolith- salts (1,3). Among true enteroliths with bilious com- induced SBO is surgical with most patients requiring position, primary enteroliths are formed in the small enterotomy or occasionally resection. Prognosis is bowel and secondary enteroliths (gallstones) are good if timely therapy is rendered, so the desire to formed in the gallbladder (1). establish a diagnosis must not delay treatment because Enterolith formation is thought to be secondary to patients with an unresolved SBO need surgery (laparo- hypomotility or stasis, although many conditions have tomy or laparoscopy) rather than a diagnosis (14). ■ been implicated (3,6,7). Small bowel diverticulosis is a well-established pre-disposing condition, where stones References form de novo or around a central nidus such as a fruit 1. Singleton JM. Calcific enterolith obstruction of the intestine. Brit stone or undigested vegetable matter (bezoar) (2). Since J Surg, 1970;57:234-236. 2. Hayee B, Khan HN, Al-Mishlab T, et al. A case of enterolith there were no small bowel diverticula in our case, we small bowel obstruction and jejunal diveticulosis. World J Gas- hypothesize that hypomotility or stasis—due to advanced troenterol, 2003;9:883-884. 3. Klinger PJ, Seelig MH, Floch NR, et al. Small intestinal age, immobility, and possibly diltiazem (8–10)—led to enteroliths: unusual cause of small intestinal obstruction: report the formation of the enterolith. Radiological diagnosis of of three cases. Dis Colon & Rectum, 1999;42:676-679. 4. Shocket E, Simon SA. Small bowel obstruction due to enterolith a primary enterolith is uncommon unless it is calcified, (bezoar) formed in a duodenal diverticulum: a case report and which usually only occurs in the more alkaline ileum (4). review of the literature. Am J Gastroenterol, 1982; 77:621-624. 5. Gupta SK, Shirbhate NC, Khanna NN, et al. Enterolithiasis. Conceivably, age-related hypochlorhydria and proton J Postgrad Med, 1982;28: 225-228. pump inhibition (pantoprazole) could have created an 6. Lopez PV, Welch JP. Enterolith intestinal obstruction owing to alkaline milieu in the proximal small bowel resulting in acquired and congenital diverticulosis: report of two cases and review of the literature. Dis Colon Rectum, 1991; 34:941-944. calcium deposition in the jejunum. 7. Coster DD, Mouw BD, Kollmorgen RL. Primary small intestinal Gallstone ileus, or SBO due to a gallstone (sec- enteroliths. Surg Rounds, 1991;7:623-624. 8. Mantzoros CS, Prabhu AS, Sowers JR. Paralytic ileus as a result ondary enterolith), occurs in about 1 in 200 patients of diltiazem treatment. J Intern Med, 1994;235:613-614. with cholelithiasis (11). The average age at presenta- 9. Fauville JP, Hantson P, Honore P, et al. Severe diltiazem poison- ing with intestinal pseudo-obstruction: case report and toxicolog- tion is 70, and it accounts for 25% of nonstrangulated ical data. J Toxicol Clin Toxicol, 1995;33: 273-277. SBO’s in those over 65 years of age (11,12). On the 10. Harada T, Ohtaki E, Sumiyoshi T, et al. Paralytic ileus induced by the combined use of nifedipine and diltiazem in the treatment other hand, there are fewer than 100 reported cases of of vasospastic angina. Cardiology, 2002;97:113-114. primary enteroliths causing SBO (6,13). While the 11. Reisner RM, Cohen JR. Gallstone ileus: A review of 1001 stone analysis in our case revealed an amorphous com- reported cases. Am Surg, 1994; 60:441-446. 12. Clavien PA, Richon J, Burgan S, et al. Gallstone ileus. Br J Surg, ponent containing bilious byproducts, the gallbladder 1990;77:737-742. and common bile duct were normal by CT and at 13. Yang HK, Fondacaro PF. Enterolith ileus: a rare complication of duodenal diverticula. Am J Gastroenterol, 1992;87:1846-1848. laparoscopy, which strengthens the evidence that our 14. Lobo DN, Braithwaite B, Fairbrother BJ. Enterolith Ileus Com- case was a primary enterolith. Therefore, given the plicating Jejunal Diverticulosis. J Clin Gastroenterol, 1999; absence of findings for gallstone ileus and the radio- 29:192-193. density and composition of the large amorphous stone, our case represents a calcified primary enterolith caus- ing proximal SBO. Only one other case of proximal SBO caused by a calcified enterolith has been reported PRACTICAL (2), but our case is unique due to the absence of small bowel diverticula. GASTROENTEROLOGY R E P R I N T S CONCLUSION For further details on rates or to place an order, In the clinical setting of a SBO due to a mass, visit our web site at: enteroliths must be considered in the differential diag- www.practicalgastro.com nosis when there is no evidence of gallstone ileus or

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