An ethanol extract of Aristolochia indica roots decreased fertility in both rats and hamsters when administered postcoitally (days 1-10 and 1-6, respectively). Petroleum ether (A), CHCl3 (B), and aqueous (C) fractions, tested similarly in rats, were inactive and/or toxic. Partition of fraction B afforded non-acidic (D) and acidic (E) fractions. Savinin (1), isolated from fraction D and not previously reported from the Aristolochiaceae , was inactive when administered postcoitally to rats. Aristolochic acid-I (2), reported previously from A. indica and isolated from fraction E, was inactive when administered postcoitally to rats and toxic when administered postcoitally to hamsters. (12S)-7,12- Secoishwaran -12-ol (3), previously reported from A. indica and isolated from fraction A, did not interrupt pregnancy when administered to mice on day 6 of pregnancy. Four additional compounds, aristolic acid (4) [prepared from aristolochic acid-I (2)], methyl aristolate (5) [prepared by methylating aristolic acid (4)], and cis- and trans-p-coumaric acid (both oblate commercially), were similarly tested in mice and found to be inactive. Aristolic acid (4), and the cis- and trans-p-coumaric acids also were inactive when administered postcoitally (days 1-10) to rats. Seven compounds reported previously from A. indica were also isolated, as were a new naphthoquinone, aristolindiquinone (6) (fraction E), and magnoflorine (fraction C).

Recurrent gallstone ileus, thought to be a rare condition, may have an incidence as high as 8.2%. 1 We describe the second reported case of three consecutive episodes of gallstone ileus and ask the question whether recurrent gallstone ileus justifies definitive surgery to the fistula itself or can be safely managed by repeated enterotomies. Case historyAn 87-year-old woman presented with a 48-h history of colicky abdominal pain and bilious vomiting. She was dehydrated and had a distended abdomen consistent with small bowel obstruction demonstrable on plain Xray films. Computed tomography (CT) showed a thickened gallbladder containing two large stones and gas consistent with a cholecystoduodenal fistula. The small bowel was distended up to the site of an intraluminal gall stone ( Fig. 1).Laparotomy was performed and, through an enterotomy, a large stone was delivered. There were no other stones or strictures found on palpating the rest of the small bowel. Her recovery was uneventful and she was discharged a week later.Nine days later, she was re-admitted with small bowel obstruction. There was superficial surgical site infection. CT scan showed a recurrence of gallstone ileus with a single cuboidal stone approximately two-thirds of the way along the small bowel. On this occasion, there was one cuboidal stone seen in the gallbladder. A further midline laparotomy was performed and an obstructing gallstone was removed from the distal ileum through an enterotomy. The skin was left open because of the established infection of the previous operative site. She made a slow recovery and was discharged on the 23rd postoperative day.Thirty-four days after discharge, she had a third episode of small bowel obstruction. CT scan showed a 28-mm gallstone impacted in the mid small bowel with no gallbladder stone.As she had an open abdominal wound from her previous mid-line laparotomy, an oblique right-sided incision over the site of the gallstone, as located on the CT scan, was made. Segmental small bowel resection and end-to-end anastomosis was performed. She made an uneventful recovery.On follow-up 12 months later, she had no recurrence of symptoms and her liver function tests were normal. Recurrent recurrent gallstone ileus Z HUSSAIN, MS AHMED, DJ ALEXANDER, GV MILLER, S CHINTAPATLAGeneral Surgery Department, York Hospitals NHS Foundation Trust, York, UK ABSTRACT We describe the second reported case of three consecutive episodes of gallstone ileus and ask the question whether recurrent gallstone ileus justifies definitive surgery to the fistula itself or can be safely managed by repeated enterotomies.

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