Iron-deficiency anaemia caused by an enterolith-filled jejunal duplication cyst

Abstract

A 48-year-old female school-bus driver presented with a 3-month history of loin pain in the absence of any change in bowel habit, excessive menstrual bleeding, or urinary symptoms. On examination, she was clinically anaemic, and routine blood screening revealed hypochromic and microcytic anaemia (Hb 9.8 g/dl, MCV 72.4 fl, MCH 23.4 pg). Barium enema radiography, colonoscopy and oesophago-gastro-duodenoscopy with duodenal mucosal biopsy were normal, as were an intravenous ureterogram and an ultrasound scan of the abdomen.Barium follow-through radiography ( Fig. 1) revealed oval filling defects in the distal ileum suggestive of enteroliths within a diverticulum. There was no evidence of intraluminal strictures and the initial diagnosis was presumed to be enteroliths within a Meckel's diverticulum.Laparotomy revealed a 10-cm diameter cystic mass containing enteroliths on the mesenteric border at the level of mid-jejunum. The rest of the small bowel appeared normal. A small bowel resection including the cystic mass (Fig. 2) was carried out and an end-to-end anastomosis was performed.Slicing the cyst revealed its contents to include multiple round, dark stones (Fig. 3). These were subsequently analysed and found to be 100% organic in nature possibly glycine. There was a single 0.3-cm diameter communication between the cystic mass and the adjacent small bowel (Fig. 4). The muscularis propria appeared in continuity between the bowel and the cyst. Microscopically, the cyst was lined with gastric epithelium. The lining of the communication showed pyloric metaplasia with adjacent mucosal erosions. Overall, these features amounted to those of an enterogenous (duplication) cyst lined with heterotopic gastric mucosa.Postoperatively, the patient recovered well. Three months following discharge from hospital, blood parameters have returned to normal (Hb 11.6 g/dl, MCV 84.7 fl, MCH 28.7 pg). DiscussionEnteric duplication cysts are rare developmental anomalies of the small intestine thought to arise at about 8-9 weeks of gestation when all layers of the bowel wall are 'pinched off'. Enterogenous duplication cysts are rare, but recognised, developmental anomalies. Duplications in the midgut are the commonest of these rare anomalies with a high proportion of them being found in the jejunum. Enterolith formation within these duplication cysts is uncommon as is heterotopic mucosa giving rise to peptic ulceration. Mode of presentation depends on whether symptoms due to mass effect or gastrointestinal bleeding predominate. We present a case of iron-deficiency anaemia caused by an enterolith-filled jejunal duplication cyst diagnosed at laparotomy and treated by surgical excision and small bowel resection.

An unusual colonic duplication associated with a foreign body and anemia: a tale of 2 colons

“…Most commonly, this is a short-term episode of very significant GI hemorrhage. More rarely, patients have occult bleeding and even iron deficiency anemia such as we encountered in this patient [16,17]. Regardless of the rate of hemorrhage, the etiology of this bleeding is usually attributed to ulcerations within duplications that contain ectopic gastric mucosa.…”

Enterolithiasis

“…Intestinal gangrene in association with enterolith has been previously reported [7] . Additional rare complications of enterolithiasis include intussusception of small bowel [81] , acute obstructive ascending cholangitis due to periampullary duodenal stone [82] , afferent loop syndrome [23,83] , diverticulitis [63,84] , iron deficiency anemia [85] , gastrointestinal hemorrhage [45] , and perforation [7,16,19,86,87] . Mortality of uncomplicated primary enterolithiasis is very low, but may rise to 3% in the poorly conditioned patients with significant obstruction and delay in diagnosis [42] .…”

Unusual Case of Jejunal Duplication in A64-Year-Old Female

“…Cholecystitis with cholesterolosis were shown on gallbladder histology. DISCUSSION Alimentary tract duplications are rare congenital anomalies that arise at about 8-9 weeks of gestation [3]. They occur in one of every 4000-5000 live births [6].…”

“…The main preoperative diagnostic modalities of duplication consist on ultrasonography, barium radiography, CT scan, and MRI. At acute presentation the laparotomy/ laparoscopy is the mainstay of diagnosis [3].…”

“…The treatment of choice of small enteric duplications is surgical excision and small bowel resection with primary re-anastomosis [3]. Partial excision and stripping of the mucosa within the duplication is an option in longer tubular duplications, and that's to avoid short bowel syndrome.…”