A case of enterolith small bowel obstruction and jejunal diverticulosis

We reported a case of 79-year old woman with known large bowel diverticulosis presenting with small bowel obstruction due to stone impaction - found on plain abdominal X-ray. Contrast studies demonstrated small bowel diverticulosis. At laparotomy, the gall bladder was normal with no stones and no abnormal communication with small bowel - excluding the possibility of a gallstone ileus. Analysis of the stone revealed a composition of bile pigments and calcium oxalate. This was a rare case of small bowel obstruction due to enterolith formation - made distinctive by calcification (previously unreported in the proximal small bowel).     

Enterolith Ileus: A Rare Complication of Duodenal Diverticula

Small bowel obstruction secondary to an enterolith formed within a duodenal diverticulum is a rare complication. Twenty-nine cases of enterolith ileus have been reported in the literature. This is a case report of the 30th, with review of the literature. Enterolith ileus closely resembles gallstone ileus in its clinical presentation. Diagnosis is established by documenting normalcy of gallbladder and the presence of small bowel diverticula.     

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.     

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.     

Hashimoto's encephalopathy after interferon therapy for hepatitis C virus in adult liver transplant recipient accompanied by post‐transplant lymphoproliferative disorder related to Epstein–Barr virus infection

T. Hori, F. Oike, K. Hata, M. Nishikiori, Y. Ogura, K. Ogawa, Y. Takada, H. Egawa, J.H. Nguyen, S. Uemoto. Hashimoto's encephalopathy after interferon therapy for hepatitis C virus in adult liver transplant recipient accompanied by post‐transplant lymphoproliferative disorder related to Epstein–Barr virus infection
Transpl Infect Dis 2010: 12: 347–352. All rights reserved Abstract: A 55‐year‐old woman underwent living‐donor liver transplantation (LDLT). She had no history of autoimmune diseases. Spleen was preserved. Steroids were withdrawn at 3 months after LDLT. Epstein–Barr virus (EBV) infection occurred at 3.5 years after LDLT. Recurrent hepatitis C virus infection was confirmed at 4.5 years after LDLT, and pegylated interferon was introduced. Diagnosis of EBV‐positive post‐transplant lymphoproliferative disorder (PTLD) was made at 4.8 years after LDLT, and tacrolimus (Tac) was stopped completely. Then, unconsciousness, convulsion, and cervical stiffness appeared suddenly. Electroencephalography, cerebrospinal fluid analysis, and image studies revealed normal or only nonspecific findings. The patient was in a state of exhaustion; therefore, steroid pulse therapy (SPT) was attempted. Surprisingly, her general condition, including consciousness disturbance, was improved markedly, and Hashimoto's encephalopathy (HE) was suspected, based on this reaction to SPT. Elevations of anti‐thyroglobulin antibody and anti‐thyroid peroxidase antibody were confirmed. After withdrawal of Tac, and treatment with acyclovir and steroids, EBV‐positive PTLD and HE improved, although they recurred at 5.1 years after LDLT. SPT improved only neurological symptoms. Molecular‐targeted therapy was given for recurrent PTLD, based on analysis of sampling specimens. This therapy was effective, but tumor lysis syndrome occurred, and the patient died at 5.3 years after LDLT.     

Diagnosis of gallstone ileus by serial computed tomography

An unusual case of choledocholithiasis followed by gallstone ileus documented by serial computed tomography is reported. A 91-year-old woman underwent gastrostomy because she repeatedly developed aspiration pneumonia, and a common bile duct stone was detected. She and her family refused surgery once symptoms resolved. One year later, she presented with increasing, intermittent abdominal pain and nausea. Abdominal computed tomography revealed a common bile duct stone with inflammatory changes, but the patient still refused surgery. Three months later, she was admitted with abdominal pain and vomiting. On admission, plain abdominal radiographs demonstrated proximal small bowel obstruction. A long ileus tube was inserted through the gastric fistula. Two days after admission, gallstone ileus was diagnosed on abdominal computed tomography based on the presence of pneumobilia, disappearance of the common bile duct stone, fluid-filled bowel loops, and the discovery of an impacted stone in the small bowel. Ten and 15 days after admission, repeated computed tomography demonstrated the impacted stone in the terminal ileum. Seventeen days after admission, a laparotomy was performed, and a 5x3-cm gallstone was removed through an ileotomy.     

Sclerosing encapsulating peritonitis in a liver transplant patient： A case report

We report a patient with HBV-related hepatocellular carcinoma (HCC) and refractory ascites who had received a peritoneal-venous shunt (PVS) 1 year before liver transplantation. Urgent surgical intervention following bowel obstruction and failure of immunosuppression therapy. No intestinal obstruction was found during an initial PVS. However, intestinal obstruction developed 2 wk after liver transplantation; and a cocoon abdomen was found upon exploration. This is the first reported case of cocoon abdomen caused by PVS and exacerbated by liver transplantation.     

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.     

Living-donor liver transplantation for autoimmune hepatitis and autoimmune hepatitis-primary biliary cirrhosis overlap syndrome

Aim: Recurrent autoimmune hepatitis (AIH) following liver transplantation has been reported in 20–30% of cases, mainly of Western populations. The aim of this study was to review our experience of living‐donor liver transplantation (LDLT) in Japanese patients with AIH. Methods: Among 375 adult (age ≥18 years) LDLT performed at our center between 1996 and 2010, 16 (4.2%) were for patients with AIH (n = 12) or AIH–primary biliary cirrhosis overlap syndrome (n = 4). The patient and donor characteristics and post‐transplantation course were reviewed. Results: All recipients were female with a median age of 48 years (range, 21–58). Low‐dose methylprednisolone and calcineurin inhibitors were continued in all patients. Acute cellular rejection occurred in 10 (63%), which was more frequent than in our overall series of 28.5% (107/375 cases). Overall survival rate was 81.2% at 5 years. At the end of the follow up (median, 6.0 years [range, 0.1–9.6]), 13 patients were alive with normal liver function tests (aspartate transaminase, 18 ± 5 IU/mL; alanine transaminase, 16 ± 8 IU/mL). None of the survivors exhibited liver function test results suspicious for recurrent AIH, which might indicate liver biopsy. Conclusion: Survival after LDLT for AIH and overlap syndrome was excellent and there was no evidence of clinical recurrence. The recurrence rate of AIH after liver transplantation may differ among countries, and requires further investigation.     

Digestive complications of biliary gallstone lost during laparoscopic cholecystectomy

A patient was admitted because of an intestinal obstruction. Eight years before, he underwent a laparoscopic cholecystectomy. Abdominal ultrasonography and small bowel series showed a gallstone in the small bowel that computed tomography scan failed to identify. Laparotomy showed a Meckel's diverticula and a biliary stone in the terminal ileum. In the literature, it has been shown that gallstone lost during laparoscopic cholecystectomy may be responsible for intraperitoneal abscess. In the contact of intestine, the stone may induce an obstructive abscess, a communicating abscess, a digestive fistula or a biliary ileus. During the postoperative course of laparoscopic cholecystectomy, these patients suffer from abdominal pain and fever lasting from few days to several months. Imaging shows the biliary gallstone mechanical complications induced by the stone. To avoid such complications, biliary gallstone that falls into the peritoneum during laparoscopic cholecystectomy should be removed under laparoscopy.     

Gallstone ileus: Case report and literature review

Gallstone ileus(GI)is characterized by occlusion of the intestinal lumen as a result of one or more gallstones.GI is a rare complication of gallstones that occurs in1%-4%of all cases of bowel obstruction.The mortality associated with GI ranges between 12%and 27%.Classical findings on plain abdominal radiography include:(1)pneumobilia;(2)intestinal obstruction;(3)an aberrantly located gallstone;and(4)change of location of a previously observed stone.The optimal management of acute GI is controversial and can be:(1)enterotomy with stone extraction alone;(2)enterotomy,stone extraction,cholecystectomy and fistula closure;(3)bowel resection alone;and(4)bowel resection with fistula closure.We describe a case to highlight some of the pertinent issues involved in GI management,and propose a scheme to minimize recurrent disease and postoperative complications.We conclude that GI is a rare condition affecting mainly the older population with a female predominance.The advent of computed tomography and magnetic resonance imaging has made it easier to diagnose GI.Enterotomy with stone extraction alone remains the most common surgical method because of its low incidence of complications.     

Infectious complications in living‐donor liver transplant recipients: a 9‐year single‐center experience

Background. Infectious complications following living‐donor liver transplantation (LDLT) remain a major cause of morbidity and mortality. We analyzed the frequency and type of infectious complications according to the post‐transplantation period, and their risk factors with regard to morbidity and mortality. Methods. We retrospectively analyzed 208 subjects who had undergone LDLT during a 9‐year period. Results. The rate of infection was 1.69 per patient during the study period. The predominant infections were intra‐abdominal infections (37.6%), primary bacteremia (17.4%), and pneumonia (14.5%). Within the first post‐transplant month, 140 (39.9%) infections were detected, and catheter‐related coagulase‐negative staphylococci (44) were the most common infectious agents. During the 2–6‐month post‐transplant period, 109 infectious episodes occurred (31.1%), and Enterococcus sp. (n=16) related to biliary infection was the most frequent isolate. After the sixth month, 96 infectious episodes (29%) occurred, and biliary tract‐related Escherichia coli (n=19) was the major causative organism. The overall mortality was 24.5% (51/208); 1‐year survival rate was 88% (196/208). Post‐transplant infection‐related mortality was 52.9% (27/51). Biliary tract complications, such as biliary stenosis or leakage, significantly increased the mortality (P=0.01); however, reoperation (retransplantation or resurgery for biliary tract obstruction/leakage or to control bleeding) significantly reduced the mortality (P=0.01). Conclusions. Our data showed that early catheter removal would mainly aid in reducing infectious complications in the 1‐month post‐transplantation period. Aggressive management, including reoperation, would lower the mortality in the LDLT recipients.     

Enterolith Ileus Resulting from Small Bowel Diverticulosis

Small intestine diverticula are infrequent. These acquired pulsion diverticula are postulated to be a result of intestinal dyskinesis. Usually asymptomatic, they can produce a variety of disorders such as malabsorption, hemorrhage, diverticulitis, and perforation. The rarest complication appears to be enterolith formation and obstruction. It is postulated that dyskinesis and stasis leads to bacterial overgrowth causing decomposition of bile salts allowing precipitation and concretion. Presented is an ileal obstruction from a small bowel enterolith. A literature review revealed 25 other cases of obstruction. Most of these cases were treated with simple removal, some with small bowel resection. Results are good and recurrences have not been observed.     

The benign course of liver disease in adults with cystic fibrosis and the effect of ursodeoxycholic acid

Background and Aims: The life expectancy of patients with cystic fibrosis (CF) has been increasing and the associated liver disease has emerged as a significant medical issue. Our aim was to describe the clinical features, course and effect of ursodeoxycholic acid (UDCA) on liver disease in an adult CF population. Study: From 1983 to 2005, 278 patients with CF were followed up at the Alfred Hospital, an adult tertiary referral centre. Twenty‐seven patients (9.7%) satisfied the criteria for liver disease and their clinico‐pathological features were assessed. The effect of UDCA on hepatobiliary symptoms and biochemical parameters was determined. Results: The mean age at liver disease diagnosis was 23 years (range 8–47 years). Portal hypertension was present in 18 (67%) patients. During a median follow‐up of 7 years (range 1.5–15), variceal haemorrhage occurred in two patients and ascites in three (one spontaneously). Nine (33%) patients died and five (19%) underwent lung transplantation. There was no encephalopathy, liver transplantation or liver‐related deaths. UDCA was taken by 22 patients and was associated with a significant improvement in hepatobiliary symptoms [11/22 (50%) in the pre‐UDCA period vs 1/22 (4%) in the post‐UDCA period; P=0.0003] and a significant reduction in aspartate aminotransferase (P=0.005); alanine aminotransferase (P<0.001); γ‐glutamyltranspeptidase (P=0.021); and alkaline phosphatase (P<0.001). Conclusions: Liver disease in adults with CF is commonly complicated by portal hypertension, but morbidity and mortality associated with this in our small patient population were low. UDCA is associated with improvement in hepatobiliary symptoms and liver function tests.     

Management of venous stenosis in living donor liver transplant recipients

AIM: To retrospectively evaluate the management and outcome of venous obstruction after living donor liver transplantation (LDLT).METHODS: From February 1999 to May 2009, 1 intraoperative hepatic vein (HV) tension induced HV obstruction and 5 postoperative HV anastomotic stenosis occurred in 6 adult male LDLT recipients. Postoperative portal vein (PV) anastomotic stenosis occurred in 1 pediatric left lobe LDLT. Patients ranged in age from 9 to 56 years (median, 44 years). An air balloon was used to correct the intraoperative HV tension. Emergent surgical reoperation, transjugular HV balloon dilatation with stent placement and transfemoral venous HV balloon dilatation was performed for HV stenosis on days 3, 15, 50, 55, and 270 after LDLT, respectively. Balloon dilatation followed with stent placement via superior mesenteric vein was performed for the pediatric PV stenosis 168 d after LDLT.RESULTS: The intraoperative HV tension was corrected with an air balloon. The recipient who underwent emergent reoperation for hepatic stenosis died of hemorrhagic shock and renal failure 2 d later. HV balloon dilatation via the transjugular and transfemoral venous approach was technically successful in all patients. The patient with early-onset HV stenosis receiving transjugular balloon dilatation and stent placement on the 15th postoperative day left hospital 1 wk later and disappeared, while the patient receiving the same interventional procedures on the 50th postoperative day died of graft failure and renal failure 2 wk later. Two patients with late-onset HV stenosis receiving balloon dilatation have survived for 8 and 4 mo without recurrent stenosis and ascites, respectively. Balloon dilatation and stent placement via the superior mesenteric venous approach was technically successful in the pediatric left lobe LDLT, and this patient has survived for 9 mo without recurrent PV stenosis and ascites.CONCLUSION: Intraoperative balloon placement, emergent reoperation, proper interventional balloon dilatation and stent placement can be effective as a way to manage hepatic and PV stenosis during and after LDLT.     

Gallstone ileus one quarter of a century post cholecystectomy

Gallstone ileus is a rare but potentially serious complication of cholelithiasis. It is usually preceded by history of biliary symptoms. It usually occurs as a result of a large gallstone creating and passing through a cholecysto-enteric fistula. Most of the time, the stone will pass the GI tract without any problems, but large enough stones can cause obstruction. The two most common locations of impaction are the terminal ileum and the ileocaecal valve because of the anatomical small diameter and less active peristalsis. We present an unusual case of small bowel obstruction secondary to gallstone ileus 24 years after an open cholecystectomy.     

Relief of small bowel obstruction following colonoscopy in a case of gallstone ileus

We describe a patient who presented with mechanical obstruction of the small bowel secondary to impaction of the ileocecal valve from a gallstone. The stone impaction of the ileocecal valve was confirmed by colonoscopy. Although the stone was disimpacted, it could not be trapped and extracted during colonoscopy. Thereafter, the patient's small bowel obstruction was relieved with no further intervention. Even though surgery is the gold standard for the management of gallstone ileus. colonoscopy can be useful in management of patients with gallstone ileus in whom surgery is contraindicated. A review of the literature is also presented.     

Successful resolution of very severe hepatopulmonary syndrome following adult‐to‐adult living donor liver transplantation: Report of two cases

Hepatopulmonary syndrome (HPS) is a severe complication in patients with chronic liver disease with poor prognosis. Liver transplantation (LT) is a promising treatment for HPS; however, very severe HPS, which is defined by an arterial oxygen pressure (PaO₂) of less than 50 mmHg and a right–left intrapulmonary shunt rate of more than 20%, may be a contraindication to LT, including living donor LT (LDLT). Here, we report two cases of decompensated liver cirrhosis with very severe HPS which were resolved after adult‐to‐adult LDLT including ABO‐incompatible LDLT. Both patients required oxygen supportive therapy in combination with specialized respiratory care postoperatively, followed by improvement of oxygenation and substantial decreases of intrapulmonary shunt rate. These findings suggest very severe HPS can be resolved by LDLT, including ABO‐incompatible LDLT, and reduced graft volume did not impede the reversal of intrapulmonary shunting. Our current report may indicate that adult‐to‐adult LDLT, including ABO‐incompatible LDLT, is becoming an effective therapeutic method and prompt a review of previous reports as well as our own files with particular regard to the indication of LDLT for decompensated liver cirrhosis with very severe HPS.     

Gallstone ileus： Report of two cases and review of the literature

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.     

Adult-to-adult living donor liver transplantation for malignant metastatic melanoma to the liver

BACKGROUND:Metastases from malignant melanoma to the liver are rare in China,and surgical resection may be of potential benefit.Liver transplantation for this disease has never been reported.METHODS:We report a case of adult-to-adult living donor liver transplantation(A-A LDLT)for metastatic melanoma.With a surgical history of ocular melanoma,the recipient presented with emaciation from a large right hepatic mass which also probably had portal vein invasion.A-A LDLT was successfully performed and no postoperative complications were observed in either the donor or the recipient.Postoperative pathology confirmed the diagnosis of metastatic malignant melanoma;however no adjuvant chemotherapy was employed after transplantation.We also reviewed the literature on the surgical treatment of metastatic malignant melanoma to the liver and discussed the LDLT indications.RESULT:Recurrence occurred 6 months after surgery and the patient died from recurrence of the disease 8 months posttransplant.CONCLUSIONS:Review of the literature suggested that only a small subset of selected patients may benefit from liver resection.Large metastatic disease in the liver potentially involving a major vessel,as in this case,should be contraindicated for liver transplantation.