A Rare Cause of Small Bowel Enterolith

Abstract

Question: A 41-year-old man presented to our hospital with a 2-week history of epigastric pain. He also complained of vomiting and constipation, but denied having fever or melena. On examination, his upper abdomen was tender without muscle guarding or rebound tenderness. Laboratory data, esophagogastroduodenoscopy, and colonoscopy disclosed unremarkable abnormalities. A plain film of the abdomen revealed focally dilated small bowel loops in the left upper quadrant, suggestive of partial small bowel obstruction (Figure A). Abdominal computed tomography demonstrated a long segmental annular thickening of bowel wall in the ileum (Figure B, white arrows). Moreover, an intraluminal radiopaque mass was identified within the involved bowel lumen (Figure B, arrow). Capsule endoscopy (CE) demonstrated multiple edematous and ulcerative mucosas accompanying with luminal strictures in the ileum. A 2-cm enterolith, causing incomplete obstruction of the bowel lumen, was identified at the site of a small bowel stricture (Figure C). A subsequent double-balloon enteroscopy confirmed the presence of multiple skipped ulcers and luminal strictures in the ileum (Figure D). The patient underwent an emergency laparotomy 2 weeks later owing to a similar episode as last hospitalization. What is the cause of this small bowel enterolith? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Laparotomy showed multiple ulcerations and stenoses in the ileum, accompanying by enlarged mesenteric lymph nodes. The enterolith and capsule disappeared at laparotomy. Histopathologic examination of the resected involved segment of small bowel revealed transmural ulcers with the presence of noncaseous granuloma (Figure E, white arrow). A diagnosis of small bowel Crohn's disease was made based on the pathologic characteristics and endoscopic pictures. Enteroliths are an uncommon cause of small bowel obstruction. Small bowel obstruction caused by enteroliths can be associated with underlying diseases, such as diverticulum, stricture, radiation enteritis, tumors, chronically incarcerated hernias, or tumor. Crohn's disease is rare in the Oriental countries.1Yang S.K. Loftus Jr, E.V. Sandborn W.J. Epidemiology of inflammatory bowel disease in Asia.Inflamm Bowel Dis. 2001; 7: 260-270Crossref PubMed Scopus (190) Google Scholar In Crohn's disease, multiple areas of small bowel stenoses are relatively common, but there are only few reported cases with stenoses complicated by enterolithiasis.2Mendes Ribeiro H.K. Nolan D.J. Enterolithiasis in Crohn's disease.Abdom Imaging. 2000; 25: 526-529Crossref PubMed Scopus (17) Google Scholar These patients usually have a long-standing history of Crohn's disease. Crohn's enteroliths can occur anywhere within an affected segment of small bowel, especially the terminal ileum. Preoperative diagnosis of Crohn's enterolith is often difficult. CE has an excellent diagnostic yield in detecting small bowel Crohn's disease with its complications.3Solem C.A. Loftus Jr, E.V. Fletcher J.G. et al.Small-bowel imaging in Crohn's disease: a prospective, blinded, 4-way comparison trial.Gastrointest Endosc. 2008; 68: 255-266Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar However, it may carry a risk of capsule retention in Crohn's disease patients with bowel stricture. Segmental bowel resection with stone removal is the treatment of choice for Crohn's enteroliths.