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An interesting case of small bowel obstruction

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Q1: What is the diagnosis?

This is a case of mechanical small bowel obstruction secondary to an enterolith/bezoar the likely source of which is jejunal diverticulosis

Q2 : What is the differential diagnosis?

This includes the various intraluminal causes of small bowel obstruction such as:

  • True foreign bodies: metallic, plastic.

  • Food bolus.

  • Gallstones.

  • Concretions.

Q3: What are the other possible complications of the primary disease of the small bowel?

The possible complications include:

  • Diverticulitis

  • Haemorrhage

  • Obstruction: 1. True obstruction due to enterolith, diverticulitis, adhesions associated with inflammation, volvulus about the adhesions, and intussuception. 2. Pseudo-obstruction or motility disorder.

  • Malabsorption due to stasis and bacterial overgrowth.

  • Fistulae.

  • Asymptomatic pneumoperitoneum.

  • Malignant tumours.

Q4: What are the possible treatment options?

The simplest surgical option for small or crushable enteroliths is to milk them distally into the caecum and allow them to pass naturally. If this is not possible, the treatment of this condition is an enterotomy to remove the enterolith with or without resection of the segment of small bowel involved with diverticulosis. Resection may be advocated if the diverticulosis is localised, and is recommended for the other forms of obstruction, haemorrhage, and patients with malabsorption who do not respond to conservative management.

Discussion

The findings at laparotomy were as follows: dilated loops of small bowel seen to midileum. Obstruction at this point was due to an enterolith with collapsed distal bowel (see fig 3 in questions (p 626) and fig 1 below). Two large jejunal diverticulae 12 and 24 inches from the duodenojejunal flexure seen which were palpably empty. The gallbladder was normal with no palpable gallstones. The enterolith was milked proximally and removed via a longitudinal antimesenteric enterotomy which was closed transversely, without resection of the diverticular segment. At laparotomy it is essential to rule out the other causes of enteroliths such as gallstones (as evidenced by a cholecyst-duodenal/jejunal fistula) and to carefully palpate the entire length of the small bowel including the diverticulae for further enteroliths.

Bezoars are masses of solidified organic or non-biological material commonly found in the stomach or small bowel. Four types have been described based on their composition: phytobezoars (containing fibre and cellulose), trichobezoar, lactobezoars, and miscellaneous. The last group includes medications (hydroscopic bulk laxatives, cholestyramine, non-absorbable antacids, vitamin C tablets, and Isocal tube feeds), parasites (Ascaris lumbricoides or roundworm), and synthetic fibre.1–3 A case of carpet fibre bezoar forming at the site of a stapled intestinal anastamosis in a child with pica has been described.3 In general, the formation of bezoars in the small intestine appears to be at sites of stasis such as blind loops, tumours, and diverticulae (duodenal, jejunal, and Meckels’).4–7

The incidence of acquired jejunal diverticulosis varies from 0.2% to 1.3% on necropsy studies to 2.3% on enteroclysis.8 It is associated in 33% to 75% of cases with diverticula elsewhere in the gastrointestinal tract. Enteroliths that form in the proximal small bowel contain bile salts and are frequently radiolucent whereas as many as a third of those that form in the ileum are radio-opaque because of precipitation of mineral salts in an alkaline environment.9

The diagnosis is therefore rarely made on the preoperative plain abdominal radiograph. Computed tomography is the modality of choice for investigating patients with higher grades of small bowel obstruction where early surgical intervention is contemplated.10 There is an increasing tendency to utilise computed tomography to help define the cause, severity, and complications of small bowel obstruction due to the unreliability of clinical signs to predict accurately those patients requiring early intervention.11

This is an unusual cause of small bowel obstruction that needs prompt diagnosis and operative treatment.

Final diagnosis

Enterolith causing small bowel obstruction.

References

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