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When radiology meets gastroenterology: an unusual impact
  1. Grigoriy E Gurvits
  1. Correspondence to Dr Grigoriy E Gurvits, Division of Gastroenterology, New York University School of Medicine/Langone Medical Center, 240 East 38 Street, 23 Floor, New York, NY 10016, USA; g_gurvits{at}hotmail.com

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Clinical presentation

A 37-year-old male with small intestinal Crohn's disease requiring distant previous ileal resection and currently in clinical remission without medical therapy was admitted to the hospital with several weeks of migrating abdominal pains that were progressively localised to the right lower quadrant and now associated with vomiting. His abdomen was distended and tender to palpation without guarding or rebound. Laboratory analysis showed haemoglobin level of 16.7 g/dL, white blood cell count of 11 800/mL, creatine level of 0.9 mg/dL, C reactive protein level of 81 mg/dL, and erythrocyte sedimentation rate of 16 mm/hour. Nasogastric tube placement was undertaken with improvement in patient's symptoms. CT imaging is shown (figure 1).

Figure 1

CT scan of abdomen and pelvis.

Question

What is the diagnosis?

Answer

CT scan revealed small bowel obstruction at ileocolonic anastomosis with adjacent rounded radiopaque density (arrow) and absence of pneumobilia (figure 1). Colonoscopy under monitored anaesthesia care showed a narrow non-ulcerated anastomotic stricture (figure 2A), which was successfully dilated to 15 mm using a balloon to allow passage of scope into the ileum, where large hard calcified object was found and removed using a Roth Net (figure 2B, C). A 2 cm perianastomotic ileal friable inflammatory-type polyp was noted and uneventfully resected during same session while ileal mucosa appeared unremarkable. Patient was subsequently discharged home in stable condition.

Figure 2

Endoscopic findings—anastomotic stricture (A), ileal (B) and retrieved (C) enteroliths.

Enterolithiasis or intestinal concretions is a rare medical finding with 0.3%–10% prevalence in setting of surgical enteroanastomoses, stricturing Crohn's disease, diverticulosis, blind pouches, tumours and intestinal tuberculosis. Choleic acid salts make up proximal enteroliths while calcification occurs in distal small intestine with increased alkalinity. Classical ‘tumbling’ of enterolith leads to fluctuating bouts of abdominal pain and distention, but acute bowel obstruction with perforation may also occur. Correct diagnosis requires high index of suspicion in patients with intestinal conditions predisposing to stasis coupled with clinical presentation and radiologic (if calcified), endoscopic or surgical visualisation of an enterolith. Mortality approaches 3%. Prompt clinical recognition and surgical or endoscopic retrieval of the enterolith is the treatment of choice1 while proper management of underlying pathology may help in preventing future bouts in susceptible patients.

Reference

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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