Enterolith Ileus as a Complication of Jejunal Diverticulosis

Abstract

Background: In a period of 5 years, 2 patients with enterolith ileus, caused by jejunal diverticulosis, were treated in our hospital. In order to learn more about treatment options, the literature was reviewed. Methods: The case history of the 2 patients is described. Relevant articles were identified using Medline^® and PubMed^®. Data regarding patient gender, age, operative findings, therapeutic measures and outcome were collected. Results: Including patients reported in the literature, 34 cases of intestinal obstruction due to enteroliths expelled from jejunal diverticula were identified. A distinction is made between complicated and uncomplicated enterolith ileus. If there are signs of bowel ischemia, other (unborn) enteroliths, inflammation of the bowel or if there are signs of a (sealed) perforation, the case is considered a complicated enterolith ileus. If none of these signs are present, uncomplicated enterolith ileus is present. In uncomplicated enterolith ileus (21 patients), more often milking and crushing or enterotomy was performed. In complicated enterolith ileus (13 patients), more often a segmental resection of the involved jejunum was performed (p < 0.01). Conclusion: Small bowel obstruction due to enteroliths expelled from jejunal diverticula is a rare condition. Relevant literature is only available in the form of case reports. On the basis of the presented patients and patients reported in the literature, a justifiable therapeutic strategy is presented. The least invasive step in the therapeutic approach is to crush and milk the obstructing enterolith down to the colon. Laparoscopic crushing and milking of the enterolith is described. If this fails an enterotomy could be tried, if possible proximal or distal from the obstruction site, in order to make an incision in a less edematous area. If the first two strategies fail, or if complicated enterolith ileus is present, resection of the involved jejunal segment could be considered.

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

“…Obstruction may be related to extrinsic compression from a nearby loop of jejunum containing a large diverticulum or from intussusception [12,22] or may be non-mechanical such as dyskinesia [23] . Obstruction may also be secondary to enterolith formation or gallstone migration.…”

“…In our case, a trial of conservative treatment was unsuccessful and thus resulted in operative intervention. Strategies, which may be used in laparotomy, are crushing of the enteroliths and milking their fragments into the colon [22,[24][25][26][27][28] . If this is unsuccessful, an enterostomy can be performed proximal or distal to the site of obstruction with the enterolith removed.…”

Enterolith Small-Bowel Obstruction Caused by Crohn's Disease

“…The consensus management of enterolith ileus at laparotomy is to attempt to manually crush the enteroliths and milk their fragments into the colon, from where they can be ejected [7,8,[17][18][19][20]. If this proves impossible, the stone can be removed through an enterotomy made in a less edematous area, proximal or distal to the obstruction site [7,20].…”

“…If these two steps fail, the primary lesion containing the enterolith must be resected [9]. Resection of the involved bowel segment may be considered in patients with complicated enterolith ileus [7,19,20] or in those with complicated diverticulosis [21,22]. In our patient, resection of the involved bowel segment was performed.…”

Jejunal diverticulae: reports of two cases with review of literature

“…Resection of the involved segment with primary end-to-end anastomosis is mostly recommended in this setting [4,19,[48][49][50]. Simple diverticulectomy is not recommended because it has been linked to postoperative leakage, sepsis and death [26].…”