Statistics from Altmetric.com
A 73-year-old woman presented with a 24-hour history of colicky abdominal pain, abdominal distension and vomiting. Medical history revealed that her bowels were opening normally and there was no history of recent change in bowel habit or weight loss. She was hypertensive and had not undergone previous abdominal surgery. The patient had previously been investigated for rectal haemorrhage when a barium enema was performed (figure 1). Examination of her abdomen revealed distension with no scars or external herniae. On auscultation tinkling bowel sounds were heard. No peritonism was present and digital rectal examination was normal. Plain abdominal radiograph was obtained (figure 2). The patient underwent an exploratory laparotomy, following which she made uneventful recovery. A post-operative small bowel enema confirmed the diagnosis (figure3).
- What is the diagnosis?
- What are the differential causes of this condition?
- What are the surgical options at laparotomy?
Mechanical small bowel obstruction.
Small bowel obstruction may be divided into luminal, intrinsic or extrinsic (box FB1). Adhesions, herniae and intra-abdominal neoplasms account for 95% of cases with all other conditions being relatively rare. At laparotomy the patient was found to have an enterolith impacted in the ileum with proximal small bowel distension and distal collapse. Multiple jejunal diverticulae were noted, commencing at the ligament of Treitz and extending distally for 45 cm. The enterolith had migrated from a diverticulum into the small bowel lumen and impacted distally causing a bolus obstruction. Extensive diverticular disease of the large bowel was also noted and the rest of the laparotomy was normal.
Small bowel obstruction due to an enterolith may be relieved either by enterotomy or by simply crushing the enterolith digitally and milking the fragments into the caecum (as was done in this case). In rare cases of small bowel diverticular disease, where intussusception, haemorrhage or perforation are present, the diseased segment should be resected and primary anastomosis performed. It may, however, be necessary to exteriorise the bowel if gross contamination or infection is present.
Obstruction caused by band adhesion or volvulus can frequently be relieved by the division of the band without resection. However, where the bowel is ischaemic or gangrenous, resection with primary anastomosis should be performed.
Jejunal diverticula are usually acquired, multiple, and located on the mesenteric border of the small bowel where the vessels penetrate the muscle. Incidence at autopsy is 0.7%,1 but this is probably an underestimate as the radiological detection rate is up to 2.3%.2 Aetiology is unclear but formation may be from disordered small bowel function and structure, leading to abnormal intestinal motility.3 Synchronous colonic diverticulosis is present in 30–61% of patients.4
Asymptomatic jejunal diverticula discovered incidentally should be left alone. About 40% of patients with small bowel diverticula are symptomatic.5 These include abdominal discomfort, flatulence, borborygmi, malabsorption, pseudo-obstruction, stasis and ‘blind loop’ syndrome. In 10% of patients surgical intervention is necessary. Reasons include intestinal obstruction, haemorrhage and perforation. Neoplastic growth may also occur and include fibroma, lipoma, carcinoma and sarcoma formation.2
Intestinal obstruction may arise from enterolith formation, intussusception or volvulus.1 6 7 In the latter situation the diverticulum acts as a pivot, especially where previous diverticulitis results in adhesive band formation. Such adhesions may also cause obstruction by direct kinking of the bowel or by trapping another loop of bowel underneath.
Mechanical small bowel obstruction secondary to an enterolith arising from jejunal diverticulum.