A Rare Case of Calcified Enterolith Presenting As Subacute Intestinal Obstruction.

Abstract

Enterolith in the small bowel is a rare phenomenon encountered on abdominal X-ray and usually is not the cause of the stricture seen simultaneously [1]. Stricture secondary to tuberculosis is the most common cause of enterolith. In our case, lymph node biopsy showed reactive lymphadenitis. As well, there were no diverticula present which is also a common cause of enterolith [2, 3] as diverticulas provide the more acidic environment necessary for choleic acid precipitation and stone formation [4]. These findings made this case a rare entity. Case Report A 32-year-old female admitted in surgery ward with complaints of pain in abdomen for 15 days and vomiting (on and off) for 4 days. Pain was predominantly in the lower abdomen. It was colicky in nature, slowly progressive, associated with vomiting, and aggravated on taking food. She had on and off vomiting which was non projectile, nonbilious, containing food particles. There was no history of diarrhea or absolute constipation. She had undergone hysterectomy 10 years back. Her abdomen was not distended. Lower midline hysterectomy scar was present and lower abdomen was tender. There was no guarding or rigidity. Bowel sounds were normally present in all four quadrants. On per rectal examination, soft fecal matter was present. X-ray abdomen anteroposterior view showed an oval radio-opaque shadow (ROS) in the area of urinary bladder. Ultrasonography (USG) was suggestive of a 4-cm-size acoustic shadow seen producing curvilinear stature away from bladder in left hemi pelvis with features of sub-acute intestinal obstruction. So impression of? Extravesical calculi? Fecolith? Calcified Lymph node came to our mind. We further proceeded with X-ray abdomen lateral view and plain computed tomography scan (CT Scan) to reach to a final diagnosis of enterolith in small bowel (Fig. 1). Fig. 1 CT showing radio-opaque shadow in small bowel Exploratory laparotomy was done. Whole bowel was explored for presence of any stone. In a segment of ileum 25 cm proximal to ileocaecal junction, a stone was found between two passable strictures, and the stone was fixed at its position. A longitudinal incision was made on the antimesenteric border of ileum at the site of distal stricture (Fig. 2). Stone was delivered out from ileum. Enterotomy incision was repaired in two layers in a transverse fashion. No other stone or any other abnormality was found in the rest of the bowel. No communicating fistula was found between gallbladder and duodenum suggesting it to be a case of primary enterolith. Fig. 2 Intraoperative picture Her post-operative period was uneventful. Stone was oval in shape around 4 cm × 3 cm, rough and hard with soft core. Biochemical study showed calcium and oxalate and cholesterol in the center.