Case report Br. J. Surg. 1992, Vol. 79, December, 1367

Enterolithiasis caused by a suture M. X. Pelling and R . M. Watkins* Departments of Radiology and *Surgery, Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK Correspondence to: Mr R. M.Watkins

Stones rarely form in the gastrointestinal as opposed to the urinary and biliary tracts. They are usually expelled by gut peristalsis before they reach appreciable size. Relative stasis occurs in a number of conditions, notably stricture and diverticula, and predisposes to precipitation of various dissolved salts. Most radio-opaque enteroliths are detected incidentally and present a diagnostic challenge. They have been associated with haemorrhage, perforation, abscess formation and obstruction. An unusual cause of enterolithiasis is described that has not previously been reported. A polypropylene (Prolene; Ethicon, Edinburgh, U K ) suture, which was accidentally passed through the jejunal wall after an incisional hernia repair, provided a static nidus. The enterolith that formed was discovered fortuitously and was initially misdiagnosed.

Case report A 54-year-old man underwent laparotomy through a midline incision for generalized peritonitis secondary to perforated appendicitis. He developed an incisional hernia which was repaired 4 years later. Following this there was an intermittent discharge of purulent fluid from the wound, which had remained painful. Some 6 years later the hernia recurred, with surrounding cellulitis. This region was explored, pus was drained and a Prolene suture was removed. A sinus track then formed and further Prolene suture material was removed. A high-output enterocutaneous fistula developed. Fistulography showed a communication with the proximal jejunum. In an adjacent loop of jejunum distal to the fistula, a 1.6-cm filling defect was noted and was thought to represent a polyp (Figure l a ) . At laparotomy, two separate fistulas were identified between the skin and jejunum. A Prolene suture passed along one fistula to enter the jejunal lumen, at which point an enterolith was identified. Division of the suture allowed its removal with the enterolith attached to one end (Figure l h ) . The segment of jejunum containing the fistulas was excised, an end-to-end anastomosis was fashioned and the recurrent incisional hernia was repaired. Biochemical analysis showed the enterolith to contain calcium, oxalate and urate.

Figure 1 a Fistulogram showing proximal jejunum with a 1~6-cmfilling defect (arrow). b Removed enterolith and suture

Discussion Enteroliths form in areas of stasis in the gastrointestinal tract. Dissolved salts often precipitate around a nidus such as a fruit seed. Their composition depends on the site of formation’. The relative acidity of the jejunum encourages precipitation of bile salts, which form radiolucent stones. The higher pH more distally favours precipitation of calcium salts, and these calculi tend to be radio-opaque. Relative stasis occurs in a number of conditions. Acquired duodenal diverticula are seen in about 5 per cent of barium studies’. Congenital diverticula can occur anywhere; Meckel’s diverticula are the most common, occurring in 1-4 per cent of people’. Bacterial overgrowth may be a further factor causing bile salts to deconjugate, thereby reducing their solubility3. Enteroliths proximal to strictures resulting from Crohn’s disease, ulcerative colitis and tuberculosis have been reported. In one series of 400 patients with tubercular strictures, 3.2 per cent showed enter~lithiasis~. An enterolith proximal to a congenital mucosal diaphragm has been reported’. Enteroliths may present incidentally or with obstruction,

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perforation or b l e e d i t ~ g ~This . ~ . case is unusual in that a suture was the nidus and the usual bowel stasis was not present. The correct diagnosis was made only at operation.

References 1.

2. 3. 4.

5.

Atwell JD, Pollock M . Intestinal calculi. Br J Surg 1960; 47: 367-14. Roshkow J, Farman J, Chen CK. Duodenal diverticular enterolith. A rare cause of small bowel obstruction. J Clin Gasfroenterol 1988; 10: 88-91. Beal SL, Walton DB, Botai BI. Enterolith ileus resulting from small bowel diverticulosis. Am J Gastroenterol 1987; 82: 162-4. Chawla S, Bery K, Indra 1. Enterolithiasis complicating intestinal tuberculosis. Clin Rudiol 1966; 17: 214-9. Levesque H P , CiriciHo DR, Sylvestre J, Gareau R, Lamarre L, Cholette C. Mucosal diaphragm and enteroliths of the small bowel causing obstruction in an adult. Am J Gastroenterol 1983; 78: 593-5.

Paper accepted 19 July 1992

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Enterolithiasis caused by a suture.

Case report Br. J. Surg. 1992, Vol. 79, December, 1367 Enterolithiasis caused by a suture M. X. Pelling and R . M. Watkins* Departments of Radiology...
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