Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis

Abstract

ABSTRACT. We present an 80-year-old man with multiple medical problems, and acute abdominal pain with feculent emesis. An unenhanced CT examination of the abdomen and pelvis demonstrated jejunal diverticulitis and findings of high-grade small bowel obstruction caused by a large enterolith. Enterolith ileus has rarely been reported in the radiology literature. This phenomenon has occasionally been reported in the surgical and gastroenterology literature. We highlight the CT findings associated with enterolith ileus in the setting of jejunal diverticulitis, to alert radiologists to this unusual diagnosis. Case reportWe present an 80-year-old man with a medical history of hypertension, diabetes, left below-the-knee amputation for arterial disease, coronary arterial stent placement, myocardial infarction, Parkinson's dementia and splenectomy. The patient presented with a 1 day history of sharp, non-radiating left lower quadrant abdominal pain and feculent emesis. The patient was afebrile on presentation. Laboratory values were notable for a leukocytosis of 27 000 and acute renal failure.An unenhanced CT examination of the abdomen and pelvis was performed to evaluate the patient's abdominal pain. The study demonstrated a large-mouth jejunal diverticulum measuring 4.1 cm by 3.9 cm (Figure 1a,b,d,e). There was inflammation and oedema of the mesentery. The findings were diagnostic of jejunal diverticulitis. A second, although not inflamed, jejunal diverticulum was noted proximally (Figure 1c). Additionally, there was a 2.9 cm by 2.1 cm lamellated and partially-calcified enterolith (Figure 2a-d). The enterolith was not located within the above-mentioned inflamed jejunal diverticulum; however, it was noted more distally within the mid-small bowel lumen causing a high-grade small bowel obstruction with a transition point at the enterolith. Collapsed small bowel loops were noted distally. CT examination from 7 years earlier showed the jejunal diverticula in retrospect although they were smaller and did not contain any enteroliths (not shown). The CT findings were then prospectively reviewed with the attending surgeon.A nasogastric tube was then placed, and approximately 1.5 l of feculent material was removed. The patient underwent laparoscopic abdominal surgery which was subsequently converted to an exploratory laparotomy after finding adherent loops of small bowel, scarring and adhesions secondary to the patient's remote splenectomy. After running the small bowel proximal to the transition point of obstruction, an enterolith was palpated and was milked intraluminally to a proximal loop of jejunum, which was also noted to have a gross perforation at the inflamed jejunal diverticular site. A 38 cm segment of small bowel was resected. Pathological evaluation of the resected small bowel demonstrated chronic diverticular disease, an ulcerated/perforated diverticulum, mesenteric microabscesses and a 3 cm enterolith. The patient was post-operatively managed in the surgical intensive care unit secondary to intra-operative hypoten...

Small bowel obstruction due to a jejunal enterolith: an unusual complication of jejunal diverticulitis

“…Even fewer describe acute small bowel obstruction due to an impacted enterolith 1. In authors knowledge, we found three similar cases where patients presented with coexisting jejunal diverticulitis with a dislodged enterolith causing acute small bowel obstruction 1–3…”

Jejunal diverticulum enterolith causing perforation and upper abdominal peritonitis

“…From a review of these case reports, enteroliths seemingly have a preponderance to cause obstruction in the mid-jejunum 3 5 6. However, there are reports of enteroliths causing obstruction in the distal jejunum7 and mid-small bowel 8…”

Faecolith arising from jejunal diverticulosis: an unusual cause of small bowel obstruction in the virgin abdomen

“…Diverticulosis of the small bowel is rare, being found in less than 5% of patients at post‐mortem examinations, and is thought to arise as a result of bowel dyskinesia, abnormal peristalsis or high intraluminal pressures . It occurs more frequently in men in their 60s and 70s .…”

“…It occurs more frequently in men in their 60s and 70s . Small bowel diverticulae occur most commonly in the duodenum (60–70%), followed by the jejunum (20–25%) and the ileum (5–10%), and are usually found on the mesenteric border of the small bowel at the site of insertion of mesenteric vessels . They are usually found incidentally either during endoscopy, on imaging or at the time of operation .…”

“…They are usually found incidentally either during endoscopy, on imaging or at the time of operation . However, complications can arise from them, including pain, diverticulitis, haemorrhage, perforation, malabsorption, blind loop syndrome, intussusceptions, stenosis and obstruction …”