Crohn's disease presenting as enterolithic intestinal obstruction

Abstract

A 44-year-old woman who had 1-year history of intermittent mild abdominal pain was admitted to the emergency ward with a 1-day history of severe abdominal pain associated with obstipation, abdominal distension, and vomiting. She denied any history of fever, altered bowel function, exposure to tuberculosis, prior abdominal surgery, anorexia, and weight loss. On examination she was afebrile, hemodynamically stable, and had moderate abdominal distension with diffuse tenderness all over. Bowel sounds were exaggerated. Anorectal examination was normal. An abdominal radiograph revealed dilated small bowel with multiple airfluid levels and five large enteroliths in erect and supine films, respectively ( Fig. 1). Her hemoglobin was 11 g%, and her white blood cell count was 9,200/mm 3 (P 78%, L 22%). Serum electrolytes and renal and liver functions were within normal limits. She was operated on after 72 hours of failed conservative treatment. Exploration revealed diffuse jejunoileal disease with sparing of the distal 60 cm of ileum. Affected bowel was thick, edematous with increased vascularity, and had mesenteric fat creeping with multiple large lymph nodes in thickened mesentery. Stomach, duodenum, colon, and bowel between the diseased segments were normal looking. There were six partial small bowel strictures: one in the distal jejunum and five in the mid ileum lying 2 to 4 cm apart. Five enteroliths of 2 cm to 5 cm in size were found in the ileum, four of which were present between the last two strictures and could not be milked in either direction. A smaller enterolith was impacted in the lumen at the distal stricture producing complete obstruction. The jejunal stricture was treated by strictureplasty and 30 cm of ileum having strictures with contained enteroliths was resected with primary anastomosis of the bowel (Fig. 2). The remaining enterolith was milked out. Opened up bowel showed transverse areas of ulceration corresponding to the stricture sites, and mucosa between strictures appeared normal. Microscopic examination revealed mucosal ulceration, focal areas of hemorrhagic necrosis, and transmural infiltration of the chronic inflammatory cells. No well-defined