Enterolith Formation in the Roux Limb Hepaticojejunostomy

Tan, Wei; Chung, Alexander Y. F.; Low, Albert; Cheah, Foong Koon; Ong, Shin-Yeu

doi:10.1007/s10620-006-9097-1

Cited by 15 publications

(14 citation statements)

References 6 publications

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“…This then leads to bacterial overgrowth, causing deconjugation of bile acids, which subsequently precipitate into aggregates when combined with choleric acid in the small bowel lumen [5]. Enteroliths have been previously described in duodenal, jejunal, and Meckel's diverticula [6][7][8]. Very uncommonly, enteroliths may enlarge, causing subsequent small bowel obstruction.…”

Section: Discussionmentioning

confidence: 99%

Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis

Garnet¹,

Scalcione²,

Barkan³

et al. 2011

BJR

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ABSTRACT. We present an 80-year-old man with multiple medical problems, and acute abdominal pain with feculent emesis. An unenhanced CT examination of the abdomen and pelvis demonstrated jejunal diverticulitis and findings of high-grade small bowel obstruction caused by a large enterolith. Enterolith ileus has rarely been reported in the radiology literature. This phenomenon has occasionally been reported in the surgical and gastroenterology literature. We highlight the CT findings associated with enterolith ileus in the setting of jejunal diverticulitis, to alert radiologists to this unusual diagnosis. Case reportWe present an 80-year-old man with a medical history of hypertension, diabetes, left below-the-knee amputation for arterial disease, coronary arterial stent placement, myocardial infarction, Parkinson's dementia and splenectomy. The patient presented with a 1 day history of sharp, non-radiating left lower quadrant abdominal pain and feculent emesis. The patient was afebrile on presentation. Laboratory values were notable for a leukocytosis of 27 000 and acute renal failure.An unenhanced CT examination of the abdomen and pelvis was performed to evaluate the patient's abdominal pain. The study demonstrated a large-mouth jejunal diverticulum measuring 4.1 cm by 3.9 cm (Figure 1a,b,d,e). There was inflammation and oedema of the mesentery. The findings were diagnostic of jejunal diverticulitis. A second, although not inflamed, jejunal diverticulum was noted proximally (Figure 1c). Additionally, there was a 2.9 cm by 2.1 cm lamellated and partially-calcified enterolith (Figure 2a-d). The enterolith was not located within the above-mentioned inflamed jejunal diverticulum; however, it was noted more distally within the mid-small bowel lumen causing a high-grade small bowel obstruction with a transition point at the enterolith. Collapsed small bowel loops were noted distally. CT examination from 7 years earlier showed the jejunal diverticula in retrospect although they were smaller and did not contain any enteroliths (not shown). The CT findings were then prospectively reviewed with the attending surgeon.A nasogastric tube was then placed, and approximately 1.5 l of feculent material was removed. The patient underwent laparoscopic abdominal surgery which was subsequently converted to an exploratory laparotomy after finding adherent loops of small bowel, scarring and adhesions secondary to the patient's remote splenectomy. After running the small bowel proximal to the transition point of obstruction, an enterolith was palpated and was milked intraluminally to a proximal loop of jejunum, which was also noted to have a gross perforation at the inflamed jejunal diverticular site. A 38 cm segment of small bowel was resected. Pathological evaluation of the resected small bowel demonstrated chronic diverticular disease, an ulcerated/perforated diverticulum, mesenteric microabscesses and a 3 cm enterolith. The patient was post-operatively managed in the surgical intensive care unit secondary to intra-operative hypoten...

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Section: Discussionmentioning

confidence: 99%

Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis

Garnet¹,

Scalcione²,

Barkan³

et al. 2011

BJR

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“…However, clinically significant enteroliths are more likely to develop in certain medical conditions. Primary enteroliths are classically formed in the areas of stasis within the bowel in the presence of the intestinal diverticula, surgical side-to-side enteroanastomoses, blind pouches (cul-de-sac), afferent loops in the Billroth Ⅱ gastrojejunostomy and Roux-en-Y procedures, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, or proximal to the intestinal strictures encountered in cases of Crohn's disease and intestinal tuberculosis [8][9][10][11][12][13][14][15][16][17][18] . It is difficult to quantify true incidence of the enterolithiasis in the setting of small intestinal diverticular disease.…”

Section: Epidemiologymentioning

confidence: 99%

“…Prevalence of enterolithiasis in patients with Meckel's diverticulum is best studied to date, and is estimated at 3%-10% [20][21][22] . Fifteen cases have been reported of post-surgical enteroliths forming after hepatojejunostomy, Billroth Ⅱ gastrojejunostomy, Rouxen-Y gastroenterostomy, and Whipple's procedures [10,23] . There are over 80 cases of enterolithiasis reported in association with intestinal tuberculosis, although most were described by Bery in a single study [24,25] .…”

Section: Epidemiologymentioning

confidence: 99%

“…Variations in structural integrity of the intestine may be seen in the diverticular disease (congenital and acquired) [8,9] ; surgical entero-anastomoses [14] , afferent or Roux loops [10] , blind pouches [13] ; stricturing or stenosing disease of the bowel seen in infectious and inflammatory conditions (tuberculosis, Crohn's disease) [11,12] ; radiation or eosinophillic enteritis [15,51] ; mucosal diaphragmatic disease [52] ; intestinal duplication [53,15] ; fistula [54] ; malignancy [55] ; and finally in apparent kinking of the gut that is found in patients with intra-abdominal adhesions, external compressions, or incarcerated hernias [15][16][17][18] . Other conditions associated with increased risk of enterolith production include intestinal aganglionosis, intestinal amoebiasis, and ischemic enteritis [15] .…”

Section: Etiologymentioning

confidence: 99%

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Enterolithiasis

Gurvits¹,

Lan²

2014

WJG

194

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Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis in the presence of the intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosing or stricturing Crohn's disease and intestinal tuberculosis. Enterolithiasis is classified into primary and secondary types. Its prevalence ranges from 0.3% to 10% in selected populations. Proximal primary enteroliths are composed of choleic acid salts and distal enteroliths are calcified. Clinical presentation includes abdominal pains, distention, nausea, and vomiting of occasionally sudden but often fluctuating subacute nature which occurs as a result of the enterolith tumbling through the bowel lumen. Thorough history and physical exam coupled with radiologic imaging helps establish a diagnosis in a patient at risk. Complications include bowel obstruction, direct pressure injury to the intestinal mucosa, intestinal gangrene, intussusceptions, afferent loop syndrome, diverticulitis, iron deficiency anemia, gastrointestinal hemorrhage, and perforation. Mortality of primary enterolithiasis may reach 3% and secondary enterolithiasis 8%. Risk factors include poorly conditioned patients with significant obstruction and delay in diagnosis. Treatment relies on timely recognition of the disease and endoscopic or surgical intervention. With advents in new technology, improved outcome is expected for patients with enterolithiasis.

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“…4 Afferent loop syndrome is generally caused by mechanical occlusion due to the recurrence or metastasis of cancer, 4–6 adhesion, 7–8 torsion, 9 internal hernia, 10 enterolithiasis, 11–12 etc., and thereafter, leads to a syndrome associated with acute abdominal symptom or acute cholangitis. On the other hand, nonobstructive afferent loop syndrome may also be caused by biliary stasis due to jejunal motility failure or the length of the blind end or jejunum, and thereafter, leads to acute cholangitis, liver abscess, and the formation of enterolithiasis and intrahepatic stones.…”

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confidence: 99%

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

Sanada

Yamada

Taguchi

et al. 2014

International Surgery

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We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

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Enterolith Formation in the Roux Limb Hepaticojejunostomy

Cited by 15 publications

References 6 publications

Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis

Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis

Enterolithiasis

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

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