Enterolith intestinal obstruction owing to acquired and congenital diverticulosis

Diverticulosis of the small bowel, complicated by enterolith formation with ensuing obturation obstruction, was recently documented in two patients. One patient had an enterolith formed within a Meckel's diverticulum; the other had an enterolith dislodged from an acquired diverticulum. Both patients presented with signs and symptoms of acute small bowel obstruction. Only 20 such cases of bowel obstruction secondary to jejunal enterolithiasis and five cases secondary to Meckel's enterolithiasis have been reported. The mechanism of obstruction may involve local encroachment or enterolith expulsion with distal bowel obstruction, although the latter is much more common. Optimally, enteroliths are broken up and milked into the proximal colon without incising the bowel. Alternatively, the enterolith may be milked proximally to a less edematous portion of bowel and an enterotomy may be performed. At times, the primary diverticulum is resected with the contained enterolith.     

Small-intestinal enteroliths—Unusual cause of small-intestinal obstruction

PURPOSE: The aim of this study was to report on a rare cause of small-intestinal obstruction caused by small-intestinal enteroliths. METHODS: We present three different cases of enterolith formation in the small intestine. One occurred after nontropical sprue, one patient had multiple jejunal diverticula, and another patient had enterolith formation in a blind loop after a small-bowel side-to-side anastomosis. RESULTS: After initial conservative therapeutic approach all patients underwent surgery. In two patients the enteroliths were removed by ileotomy or jejunostomy. In the third patient the bowel anastomosis had to be revised after removal of the enterolith. CONCLUSION: Small-intestinal enteroliths may cause small-bowel obstruction. The first therapeutic approach is nonsurgical; however, if obstruction proceeds, surgical removal with or without revision of underlying pathology is necessary. We discuss the causes and therapeutic management of enteroliths and give a review of related literature.     

Small Bowel Obstruction Due to Enterolith (Bezoar) Formed in a Duodenal Diverticulum: A Case Report and Review of the Literature

An elderly patient with an acute small bowel obstruction due to an enterolith that evolved within a duodenal diverticulum is reported. Twenty-four prior instances of small bowel obstruction due to an enterolith formed within a small bowel diverticulum have been culled from the world literature and tabulated, In toto , 18 subjects are female and seven are male. The median age is 68 yr. Optimal surgical management is either to break up the enterolith and milk the components into the cecum without an enterotomy or., as is more often necessary, to milk the enterolith orad removing the concretion through an enterotomy made in less edematous small intestine. As in managing gallstone ileus, the bowel should be "run" seeking additional enteroliths. The diagnosis can be established only by documenting the normalcy of the gallbladder and the presence of duodenal and/or jejunal diverticula.     

Radiation jejunitis and a choleic-acid enterolith

Digestive Diseases and Sciences - A case is presented of a woman with jejunal stricture resulting from X-irradiation 20 years previously and a choleic-acid enterolith lying above the site of...     

Acute lower massive digestive hemorrhage due to a jejunal angiomatoid hamartoma. Case report

Acute hemorrhage of the lower digestive tract is massive in 20% of the cases, requiring emergency surgery. In such cases, a preoperative diagnosis of the point of bleeding is essential. In order to determine this, any combination of oral panendoscopy, rectal sigmoidoscopy, colonoscopy, arteriography and isotopic studies should be used. The most frequent causes are right colonic angiodysplasia and colonic diverticulosis. The authors present a case of lower digestive bleeding due to an angiomatoid hamartoma located in the first jejunal segments, a rare pathology as a cause of hemorrhage. The diagnosis was obtained by selective arteriography. Oral panendoscopy and colonoscopy were also performed.     

Small bowel obstruction due to an unconjugated ursodeoxycholic acid enterolith following living donor liver transplantation: Report of a case

We report an unusual case of small bowel obstruction due to an ursodeoxycholic acid (UDCA) enterolith that occurred 7 years after liver transplantation. A 70‐year‐old man had undergone multiple operations, including a living donor liver transplantation (LDLT) and hepaticojejunostomy. Four years after the LDLT, cholestasis developed, for which oral UDCA was administrated. Seven years after the LDLT, he was admitted to our hospital because of pneumonia; intestinal obstruction occurred following its resolution. A radiographic contrast study and computed tomographic scan indicated a movable mass as the cause of the ileus, suggesting a giant stone. We were unable to observe or remove the stone by double balloon enteroscopy owing to the presence of severe adhesion; thus, we surgically removed the mass. The patient's postoperative course was uneventful. He was discharged 20 days after the operation. An infrared spectrophotometric analysis revealed that the stone was a true enterolith, primarily composed of unconjugated UDCA. An ileus caused by a true enterolith is a rare clinical complication of LDLT. Nevertheless, it must be considered in the differential diagnosis of intestinal obstructions in liver transplant recipients with Roux‐en‐Y hepaticojejunostomies and/or bowel stasis.     

A rare complication of jejunal diverticulosis.

Jejunal diverticulae are rare and usually asymptomatic, Jejunoileal diverticulae are generally thought to be acquired and are estimated to occur in 1-5% of the population of which only 10% developed complications which include diverticulitis, perforation, hemorrhage, enterolith formation and obstruction. We present a case of jejunal diverticulosis associated with stricture formation resulting in obstruction of the jejunum, the first reported case of this kind so far.     

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

Jejunal diverticulosis （JD） is a rare clinical entity. The potential complications of this condition are discussed here through a series of cases presented to our centre. A retrospective analysis of four cases, which were diagnosed and treated, was performed. These included two cases of gastrointestinal haemorrhage, one case of perforation and one case of enterolith obstruction. All of these cases were secondary to jejunal diverticulosis and treated surgically. This was accompanied by a literature search to identify the different modalities for diagnosis and treatment of this condition. JD is rare and may lead to a diagnostic delay. Awareness of the wide spectrum of potential complications can prevent this delay.     

Enterolith: an unusual cause of afferent loop obstruction

Most cases of enterolith have been reported in association with the diverticula of small bowel. We report here a case of a patient in whom a huge enterolith developed in the afferent loop of Billroth II anastomosis with ensuing obturation obstruction. The enterolith was clearly shown on the preoperative abdominal computed tomograph and was removed through a duodenotomy. The postulated mechanism of the enterolith formation is impaired duodenal evacuatory motor activity due to previous gastrectomy.     

Abnormalities of jejunal mucosal enzymes in ulcerative colitis and Crohn's disease.

Jejunal mucosal function and structure was examined in 31 patients with ulcerative colitis and 29 patients with Crohn's disease with ileal, ileocolonic or colonic involvement; A significant reduction of the specific activity of disaccharidases (lactase, sucrase and trehalase) in jejunal mucosal homogenate occurred in patients with inflammatory bowel disease. Similarly, alkaline phosphatase was reduced in ulcerative colitis. Several dipeptidases such as glycyl-leucine, leucyl-glycine, glycyl-glycine and valyl-proline hydrolase activities were lower in patients with inflammatory bowel disease than in controls. Histological changes in jejunal mucosal biopsies occurred in 71% of patients with ulcerative colitis and 61% with Crohn's disease. These changes ranged from mild abnormalities of villus architecture to marked reduction of villus height. Most patients with a reduction in mucosal enzymes had concommitant morphological changes in jejunal mucosal biopsy. The results of this study indicate that functional and structural abnormalities of the jejunal mucosa frequently occur in patients with inflammatory bowel disease without radiologic evidence of proximal small bowel involvement.     

Celiac Sprue in Down's Syndrome: Considerations on a Pathogenetic Link

The association of celiac disease with Down's syndrome is described in two patients who presented with features of the malabsorption syndrome. The diagnosis was readily made by peroral jejunal mucosal biopsy. Both patients responded clinically to dietary gluten withdrawal and one patient demonstrated a recrudescence of symptoms and reappearance of jejunal mucosal atrophy upon rechallenge with dietary gluten. Genetic considerations in the etiology of both disorders are discussed.     

Response of the skin in dermatitis herpetiformis to a gluten free diet, with reference to jejunal morphology.

Twenty-one patients with dermatitis herpetiformis have been on a gluten free diet regularly followed up for at least one year (mean four years). Eighteen patients had a 'flat' mucosal appearance (grade III), one patient had moderately severe mucosal abnormality (grade II), one patient had mild mucosal abnormality (grade I), and one patient had a normal mucosal appearance (grade O). On the diet, 10 patients had no skin rash and took no dapsone, seven patients controlled the skin rash on a lower dose of dapsone, and four noticed no improvement. There was no correlation between pre-diet jejunal morphology and response of the skin. A repeat jejunal biopsy, on the gluten free diet, was possible in 15 patients. While all those with skin improvement showed some improvement in jejunal morphology, there was no association between the degree of skin improvement and the degree of recovery of the jejunal mucosa.     

ENDOSCOPIC REMOVAL OF AN ENTEROLITH CAUSING AFFERENT LOOP SYNDROME USING ELECTROHYDRAULIC LITHOTRIPSY

Electrohydraulic lithotripsy is a very useful method for fragmenting biliary stones and it can be used for endoscopic removal of difficult biliary stones. Acute afferent loop syndrome induced by enterolith is very rare, and surgical treatment is the usual choice for this condition. We describe a patient with acute afferent loop syndrome, which was induced by an enterolith after a Billroth II gastrectomy. We used electrohydraulic lithotripsy to endoscopically remove the enterolith.     

Human intestinal mucosal mast cells: expanded population in untreated coeliac disease.

Previous retrospective studies of intestinal mucosal mast cells in coeliac disease have given divergent results, and we have recently reported that inappropriate methodology could account for these discrepancies. In this prospective study, mucosal mast cell counts were performed in Carnoy fixed, peroral jejunal biopsy specimens from patients with coeliac disease, both untreated and treated with a gluten-free diet; and from controls (mainly irritable bowel syndrome). Mean mucosal mast cell count in 27 control subjects was 146/mm2, SD 29. Significantly higher values were obtained in untreated coeliac disease (mean 243, SD 41, p less than 0.001) returning to the normal range in coeliacs treated with a gluten-free diet with normal jejunal biopsy morphology. In seven patients mucosal mast cell counts were performed in multiple jejunal biopsies, and these showed that mucosal mast cell distribution was not patchy. There was no evidence of degranulation of intestinal mucosal mast cells under the conditions of routine biopsy (overnight fast). An increase in mucosal mast cells in untreated coeliac disease may be one explanation for the high number of IgE positive stained cells in the intestinal mucosa that has been reported by some authors.     

Nodular lymphoid hyperplasia of the jejunal mucosa associated with hypogammaglobulinemia. Increased number of mast cells in the jejunal mucosa

A case with nodular lymphoid hyperplasia of the jejunal mucosa associated with hypo- and dysgammaglobulinemia, increased susceptibility to infections, recurrent giardia invasions, absence of plasma cells in the bone marrow and jejunal mucosal stroma and extremely increased number of mucosal mast cells has been described. The latter was supposed to be an essential morphological feature of the syndrome, that is due to a "secondary" response to repeated giardia invasions in a condition of impaired humoral but presumably normal cellular immune response. Some of the tinctorial properties of intestinal mucosal mast cells were discussed.     

Effect of ethanol on morphology and total,capillary, and shunted blood flow of different anatomical layers of dog jejunum

On the basis of previous studies in our laboratory we postulated that the ethanol-induced alteration in jejunal morphology was the result of its effect on the microcirculation. The present study was undertaken to examine the validity of this hypothesis. Accordingly, the effects of intraluminal ethanol perfusion (3.0 and 6.0% w/v) on mucosal morphology; water, glucose, and sodium transport; and regional blood flow were examined in in vivo jejunal segments of pentobarbital-anesthetized dogs. Compared to control segments, those perfused with ethanol exhibited a significant increase in the prevalence of morphological alterations of the mucosa, consisting of subepithelial fluid accumulation (bleb formation) and exfoliation. Those villi with epithelial damage exhibited villus cores significantly shorter than those with a normal, undamaged epithelium. Segments perfused with ethanol exhibited a depressed net water absorption, to the point that net secretion occurred in the segments perfused with 6% ethanol. Net absorption of glucose was similarly depressed by intraluminal perfusion with ethanol, whereas net absorption of sodium was unaffected. Regional jejunal blood flows were estimated using a dual, radiolabeled microsphere technique. Both total jejunal wall and total mucosal blood flow (in ml/min/100 g dry tissue) in the ethanol-perfused segments were significantly increased over control. Similarly, jejunal wall and mucosal capillary blood flows were increased by ethanol perfusion. Neither submucosal nor muscularis blood flows were affected by intraluminal perfusion with ethanol. Compared to control, shunting or nonentrapment of 9-micron microspheres was increased in the mucosa of the ethanol-perfused segments. In contrast to this, shunting of 9-micron microspheres in the submucosa and muscularis was unaffected by intraluminal perfusion with ethanol. It therefore appears that the ethanol-induced mucosal morphological alterations are accompanied by a localized mucosal hyperemia, and an increased shunting of blood through the mucosa. Based on the results of this and other studies, a microvascular mechanism was tentatively proposed to explain the pathogenesis of the ethanol-induced morphological changes.     

Epithelial cell renewal and turnover and relationship to morphologic abnormalities in jejunal mucosa in tropical sprue

A morphometric study confirmed that increasing severity of the jejunal mucosal morphologic lesion is accompanied by increased crypt height and reduced villus length in patients with tropical sprue. Mitotic activity in the crypts was increased. Pulse labeling of jejunal mucosal biopsies cultured in vitro with [3H]thymidine confirmed that there was increased uptake of label in tropical sprue with more rapid migration of labeled cells to the villi. The label was also lost more rapidly. Earlier ultrastructural studies have shown enterocyte damage and extrusion in the crypt and villus epithelium. The present data suggest that in the jejunal mucosa of patients with tropical sprue, the loss of damaged enterocytes leads to villus shortening and increased cell production in the crypts, with hypertrophy of the crypts.     

Diagnostic accuracy of fiberoptic panendoscopy and visceral angiography in acute upper gastrointestinal bleeding.

Emergency fiberoptic panendoscopy and visceral angiography both had comparable diagnostic accuracy in our series of 55 patients with actively bleeding upper gastrointestinal lesions. The diagnostic accuracy of the barium meal was found inferior to both fiberoptic panendoscopy and visceral angiography. Panendoscopy proved capable of quickly and safely diagnosing site and source of the active bleeding lesion. Visceral angiography requiring additional time, expense and personnel commitment proved an effective back-up procedure when panendoscopy was unsuccessful or contradictions existed. Emergency angiography was well tolerated by gravely ill patients. The therapeutic advantage of angiography with infusion of vasopressin upon completion of the diagnostic study remains to be shown as an advantage over panendoscopy.     

Enterolith Formation in the Roux Limb Hepaticojejunostomy

Enterolith in the Roux limb of Roux-en-Y hepaticojejunostomy is rare. We report a case of a Roux loop enterolith presenting with recurrent cholangitis. Cholescintigraphy and magnetic resonance imaging aided in the preoperative diagnosis. Intraoperatively, a large enterolith was extracted distal to the biliodigestive anastomosis. A kink of the small bowel was also noted distal to the stone. The mechanism for enterolith formation in the Roux loop is discussed.     

Effect of parenteral nutrition supplemented with short-chain fatty acids on adaptation to massive small bowel resection

After massive small bowel resection, total parenteral nutrition (TPN) is prescribed to maintain nutritional status. However, TPN reduces the mass of the remaining intestinal mucosa, whereas adaptation to small bowel resection is associated with increased mucosal mass. Short-chain fatty acids (SCFAs) have been shown to stimulate mucosal cell mitotic activity. This study determined whether the addition of SCFAs to TPN following small bowel resection would prevent intestinal mucosal atrophy produced by TPN. Adult rats underwent an 80% small bowel resection and then received either standard TPN or TPN supplemented with SCFAs (sodium acetate, propionate, and butyrate). After 1 wk, jejunal and ileal mucosal weights, deoxyribonucleic acid, ribonucleic acid, and protein contents were measured and compared with the parameters obtained at the time of resection. Animals receiving TPN showed significant loss of jejunal mucosal weight, deoxyribonucleic acid, ribonucleic acid, and protein and ileal mucosal weight and deoxyribonucleic acid after small bowel resection, whereas animals receiving SCFA-supplemented TPN showed no significant change in the jejunal mucosal parameters and a significant increase in ileal mucosal protein. These data demonstrate that SCFA-supplemented TPN reduces the mucosal atrophy associated with TPN after massive bowel resection and thys may facilitate adaptation to small bowel resection.