Images for surgeons
4. Medinger M, Kleinschmidt M, Mross K et al. c-kit (CD117) expression in human tumors and its prognostic value: an immunohistochemical analysis. Pathol. Oncol. Res. 2010; 16: 295–301. 5. Gold JS, Dematteo RP. Combined surgical and molecular therapy: the gastrointestinal stromal tumor model. Ann. Surg. 2006; 244: 176–84. 6. McAuliffe JC, Hunt KK, Lazar AJ et al. A randomized, phase II study of preoperative plus postoperative imatinib in GIST: evidence of rapid radiographic response and temporal induction of tumor cell apoptosis. Ann. Surg. Oncol. 2009; 16: 910–9. 7. Eisenberg BL, Harris J, Blanke CD et al. Phase II trial of neoadjuvant/ adjuvant imatinibmesylate (IM) for advanced primary and metastatic/ recurrent operable gastrointestinal stromal tumor (GIST): early results of RTOG 0132/ACRIN 6665. J. Surg. Oncol. 2009; 99: 42–7. 8. Mehta RM, Sudheer VO, John AK et al. Spontaneous rupture of giant gastric stromal tumor into gastric lumen. World J. Surg. Oncol. 2005; 3: 11.
689
9. Osada T, Nagahara A, Kodani T et al. Gastrointestinal stromal tumor of the stomach with a giant abscess penetrating the gastric lumen. World J. Gastroenterol. 2007; 13: 2385–7.
Samet Yardimci,* MD Tevfik Kivilcim Uprak,* MD Faruk Erdem Kombak,† MD Handan Kaya,† MD Sevket Cumhur Yegen,* MD *General Surgery Clinic and †Pathology Clinic, Marmara University Pendik Education and Research Hospital, I˙stanbul, Turkey doi: 10.1111/ans.12266
Faecolith arising from jejunal diverticulosis: an unusual cause of small bowel obstruction in the virgin abdomen A 92-year-old woman presented to the emergency department with absolute constipation and vomiting. The patient reported sudden onset of abdominal pain 2 days prior to her presentation. Apart from cataracts and hypertension, her medical history was unremarkable. Notably, she had not had any previous abdominopelvic surgery. She reported that she had lost approximately 5 kg in the last 6 months, but denied any other constitutional symptoms. On examination, she appeared to be dehydrated, but her observations were within normal parameters. She had a distended abdomen, generalized tenderness without guarding and absent bowel sounds. Per rectal examination revealed an empty rectum. Plain abdominal X-ray revealed distended loops of small bowel with multiple air-fluid levels (Fig. 1). She was initially managed conservatively with a nasogastric tube and no oral intake. When she failed to respond, however, a computed tomography (CT) scan was performed to look for a potential site of obstruction. The CT found a gas-filled intraluminal mass in the small bowel in the right upper quadrant. A laparoscopy was performed and a smooth, firm, mobile mass was found in the terminal ileum. A run-through of the bowel revealed multiple, large jejunal diverticulae (Fig. 2). A small midline incision was made, just large enough to deliver the loop of ileum and mass. An enterotomy was made distal to the obstruction, and the mass, which appeared to be a 4.5 × 3.5 × 2 cm faecolith (Fig. 3), was milked through the opening. The enterotomy was closed using polydioxanone sutures and the abdomen was closed in the usual fashion. No other intra-abdominal abnormalities, notably strictures, fistulae or tumours, were noted at the time of the operation. Notably, there were no cholecystoduodenal or cholecystogastric fistulae to suggest that the mass was a gallstone. Apart from delirium, which delayed her discharge by some days, her post-operative course was unremarkable and she was discharged to a local facility for further rehabilitation. Diverticulosis of the small bowel is rare, being found in less than 5% of patients at post-mortem examinations,1 and is thought to arise © 2013 Royal Australasian College of Surgeons
Fig. 1. Plain abdominal X-ray revealing distended loops of small bowel with multiple air-fluid levels.
as a result of bowel dyskinesia, abnormal peristalsis or high intraluminal pressures.2 It occurs more frequently in men3 in their 60s and 70s.4 Small bowel diverticulae occur most commonly in the duodenum (60–70%), followed by the jejunum (20–25%) and the ileum (5–10%),2 and are usually found on the mesenteric border of the small bowel at the site of insertion of mesenteric vessels.2 They are usually found incidentally either during endoscopy, on imaging or at the time of operation.3 However, complications can arise from them, including pain, diverticulitis, haemorrhage, perforation, malabsorption, blind loop syndrome, intussusceptions, stenosis and obstruction.2,5,6
690
Images for surgeons
Fig. 2. Computed tomography images showing the obstructive mass (left and centre) and multiple jejunal diverticulae (right).
Fig. 3. Faecolith extracted from the terminal ileum measuring 4.5 × 3.5 × 2 cm.
Enteroliths, or faecoliths, may be classified as true or false. True enteroliths arise from stasis and subsequent precipitation and deposition of choleic acid, which is an end product of bile salt metabolism.4,5,7 If there is an increase in pH, these enteroliths can calcify8 and become radio-opaque, although this is an uncommon finding.5,8 False enteroliths generally form around a central nidus, such as a foreign body, faecolith or bezoar (poorly digested vegetable matter that appears on CT as a mottled-appearing mass containing air).4,5 Although enteroliths can arise de novo, other factors can contribute to their formation. These include injury to the bowel lumen (from inflammation, surgery and strictures), metabolic conditions and medications that cause hypomotility.4,7 It is hypothesized that the patient discussed in this case study had a false enterolith, which had formed around a bezoar, owing to its centrally gas-filled appearance on CT. Initially, conservative management with nasogastric tube decompression and intravenous fluids is often attempted but is usually unsuccessful.2,4,7,9,10 Thus, the definitive management of enterolith bowel obstruction is surgical. If the cause of the obstruction is unclear, a laparoscopy can be performed. However, the laparoscopic approach is not recommended for crushing or milking the enterolith
due to the risk of trauma to the oedematous bowel.4 Laparotomy is therefore recommended. The enteroliths may be crushed and then milked into the distal colon.4,5,8,9 An enterotomy can also be performed distal to the obstruction where the bowel is less oedematous, and the enterolith is removed through this incision, if it is not possible to crush the enterolith.2–9 If these last techniques are unsuccessful, or if there are any complications such as focal necrosis or diverticulitis, resection of the affected segment, along with the enterolith, may be required.2,9 It is also recommended to check all the diverticulae seen and to remove any further enteroliths that may be seen to avoid recurrence.4 Enteroliths are a rare cause of small bowel obstruction; however, they should be considered, particularly those with no previous history of abdominopelvic surgery. Imaging may show the enterolith itself, or may suggest it, by the presence of small bowel diverticulae. Conservative management may be attempted; however, it is usually unsuccessful and laparotomy is often needed to resolve the obstruction. A number of techniques can be used, including crushing of the enterolith, an enterotomy to remove the enterolith or bowel resection. Any other small bowel diverticulae seen at the time of the operation should also be inspected to ensure they are not harbouring any further enteroliths, which may cause a recurrence.
References 1. Noer T. Non-Meckelian diverticula of the small bowel. Acta Chir. Scand. 1960; 120: 175–9. 2. Garnet DJ, Scalcione LR, Barkan A et al. Enterolith ileus: liberated large jejuna diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis. Br. J. Radiol. 2011; 84: 154–7. 3. Kornprat P, Langner C, Mischinger HJ. Enterolithiasis in jejuna diverticulosis, a rare cause of obstruction of the small intestine: a case report. Wien. Klin. Wochenschr. 2005; 117: 297–9. 4. Monchal T, Hornez E, Bourgouin S et al. Enterolith ileus due to jejunal diverticulosis. Am. J. Surg. 2010; 199: 45–7. 5. Hayee B, Khan HN, Al-Mishlab ET. An unusual case of enterolith small bowel obstruction and jejunal diverticulosis. World J. Gastroenterol. 2003; 9: 833–4. 6. Crace PP, Grisham A, Kerlakian G. Jejunal diverticular disease with unborn enterolith presenting as a small bowel obstruction: a case report. Am. Surg. 2007; 73: 703–5.
© 2013 Royal Australasian College of Surgeons
Images for surgeons
7. Klingler PJ, Seelig MH, Floch NR, Branton SA, Metzger PP. Smallintestinal enteroliths – unusual cause of small-intestinal obstruction: report of three cases. Dis. Colon Rectum 1999; 42: 676–9. 8. Shocket E, Simon SA. Small bowel obstruction due to enterolith (bezoar) formed in a duodenal diverticulum: a case report and review of the literature. Am. J. Gastroenterol. 1982; 77: 621–4. 9. Steenvoorde P, Schaardenburgh P, Viersma JH. Enterolith ileus as a complication of jejunal diverticulosis: two case reports and a review of the literature. Dig. Surg. 2003; 20: 57–60.
691
10. Efremidou EI, Liratzopoulos N, Papageorgiou MS et al. Enterolith small-bowel obstruction caused by jeunal diverticulosis. Surg. Today 2006; 36: 1003–6.
Tam Quinn, MBBS, BMedSci, PGDipSurgAnat Paul Strauss, MBBS, FCS (SA) Department of General Surgery, Central Gippsland Health Service, Sale, Victoria, Australia doi: 10.1111/ans.12301
Pseudocysts secondary to retained gallstones post-laparoscopic cholecystectomy An 88-year-old gentleman was investigated for 6 weeks of rightsided abdominal and flank pain associated with bulging in the flank region. There were no associated constitutional symptoms such as fevers, sweats or reported weight loss. The patient was otherwise medically well and the only history of any real note was that of a laparoscopic cholecystectomy performed 12 years prior without apparent complication. Ultrasound examination and subsequent helical computerized tomography (CT) scanning with intravenous and oral contrast was performed. This demonstrated two cystic foci containing calcified material (Figs 1,2). The first measured 8 cm and was contained within Morrison’s pouch. This lesion was noted to be discharging into the adjacent intercostal space. The second lesion measuring 7 cm was noted medial to the caecum, centred on the small bowel mesentery. The initial suggestion from the radiologist was that these lesions were hydatid cysts. A trial of empirical treatment with albendazole was undertaken. Hydatid serology was performed and was negative. Other blood tests including C-reactive protein and white cell count were unremarkable. Surgical review was obtained and given the past history of cholecystectomy, and faceted appearance of the calcified areas within the lesions, it was
thought they were likely related to retained gallstones. The patient underwent a laparotomy and had complete excision of two cystic lesions, corresponding to the cystic foci on the CT scans. Retained gallstones were evident in both cavities (Fig. 3). Histopathology demonstrated thick fibrous walled lesions lined by florid xanthogranulomatous inflammation an appearance consistent with pseudocysts. Post-operatively, the patient recovered well with resolution of his symptoms of pain and a mass. The laparoscopic approach to cholecystectomy has become the method of choice, resulting in high rates of patient satisfaction and rapid recovery from surgery. However, compared with open surgery, there is an increased incidence of gallstone spillage and retrieval of spilt stones is more difficult in laparoscopic scenarios. The reported incidence of gallstone spillage in the literature for laparoscopic cholecystectomy varies widely, ranging from 6–30%.1–3 In most cases, gallstone spillage does not result in any adverse sequelae; however, it should be noted that complications can arise many years later as in this case. Overall, complications are estimated to occur in less than 1% of cases.4 The main complication that can occur is abscess formation around the stone, although other complications have been reported including enterocutaneous fistula formation, migration into the
Fig. 1. Coronal CT demonstrating cystic foci with calcified material.
Fig. 2. Axial CT demonstrating cystic foci with calcified material.
© 2013 Royal Australasian College of Surgeons
4. Medinger M, Kleinschmidt M, Mross K et al. c-kit (CD117) expression in human tumors and its prognostic value: an immunohistochemical analysis. Pathol. Oncol. Res. 2010; 16: 295–301. 5. Gold JS, Dematteo RP. Combined surgical and molecular therapy: the gastrointestinal stromal tumor model. Ann. Surg. 2006; 244: 176–84. 6. McAuliffe JC, Hunt KK, Lazar AJ et al. A randomized, phase II study of preoperative plus postoperative imatinib in GIST: evidence of rapid radiographic response and temporal induction of tumor cell apoptosis. Ann. Surg. Oncol. 2009; 16: 910–9. 7. Eisenberg BL, Harris J, Blanke CD et al. Phase II trial of neoadjuvant/ adjuvant imatinibmesylate (IM) for advanced primary and metastatic/ recurrent operable gastrointestinal stromal tumor (GIST): early results of RTOG 0132/ACRIN 6665. J. Surg. Oncol. 2009; 99: 42–7. 8. Mehta RM, Sudheer VO, John AK et al. Spontaneous rupture of giant gastric stromal tumor into gastric lumen. World J. Surg. Oncol. 2005; 3: 11.
689
9. Osada T, Nagahara A, Kodani T et al. Gastrointestinal stromal tumor of the stomach with a giant abscess penetrating the gastric lumen. World J. Gastroenterol. 2007; 13: 2385–7.
Samet Yardimci,* MD Tevfik Kivilcim Uprak,* MD Faruk Erdem Kombak,† MD Handan Kaya,† MD Sevket Cumhur Yegen,* MD *General Surgery Clinic and †Pathology Clinic, Marmara University Pendik Education and Research Hospital, I˙stanbul, Turkey doi: 10.1111/ans.12266
Faecolith arising from jejunal diverticulosis: an unusual cause of small bowel obstruction in the virgin abdomen A 92-year-old woman presented to the emergency department with absolute constipation and vomiting. The patient reported sudden onset of abdominal pain 2 days prior to her presentation. Apart from cataracts and hypertension, her medical history was unremarkable. Notably, she had not had any previous abdominopelvic surgery. She reported that she had lost approximately 5 kg in the last 6 months, but denied any other constitutional symptoms. On examination, she appeared to be dehydrated, but her observations were within normal parameters. She had a distended abdomen, generalized tenderness without guarding and absent bowel sounds. Per rectal examination revealed an empty rectum. Plain abdominal X-ray revealed distended loops of small bowel with multiple air-fluid levels (Fig. 1). She was initially managed conservatively with a nasogastric tube and no oral intake. When she failed to respond, however, a computed tomography (CT) scan was performed to look for a potential site of obstruction. The CT found a gas-filled intraluminal mass in the small bowel in the right upper quadrant. A laparoscopy was performed and a smooth, firm, mobile mass was found in the terminal ileum. A run-through of the bowel revealed multiple, large jejunal diverticulae (Fig. 2). A small midline incision was made, just large enough to deliver the loop of ileum and mass. An enterotomy was made distal to the obstruction, and the mass, which appeared to be a 4.5 × 3.5 × 2 cm faecolith (Fig. 3), was milked through the opening. The enterotomy was closed using polydioxanone sutures and the abdomen was closed in the usual fashion. No other intra-abdominal abnormalities, notably strictures, fistulae or tumours, were noted at the time of the operation. Notably, there were no cholecystoduodenal or cholecystogastric fistulae to suggest that the mass was a gallstone. Apart from delirium, which delayed her discharge by some days, her post-operative course was unremarkable and she was discharged to a local facility for further rehabilitation. Diverticulosis of the small bowel is rare, being found in less than 5% of patients at post-mortem examinations,1 and is thought to arise © 2013 Royal Australasian College of Surgeons
Fig. 1. Plain abdominal X-ray revealing distended loops of small bowel with multiple air-fluid levels.
as a result of bowel dyskinesia, abnormal peristalsis or high intraluminal pressures.2 It occurs more frequently in men3 in their 60s and 70s.4 Small bowel diverticulae occur most commonly in the duodenum (60–70%), followed by the jejunum (20–25%) and the ileum (5–10%),2 and are usually found on the mesenteric border of the small bowel at the site of insertion of mesenteric vessels.2 They are usually found incidentally either during endoscopy, on imaging or at the time of operation.3 However, complications can arise from them, including pain, diverticulitis, haemorrhage, perforation, malabsorption, blind loop syndrome, intussusceptions, stenosis and obstruction.2,5,6
690
Images for surgeons
Fig. 2. Computed tomography images showing the obstructive mass (left and centre) and multiple jejunal diverticulae (right).
Fig. 3. Faecolith extracted from the terminal ileum measuring 4.5 × 3.5 × 2 cm.
Enteroliths, or faecoliths, may be classified as true or false. True enteroliths arise from stasis and subsequent precipitation and deposition of choleic acid, which is an end product of bile salt metabolism.4,5,7 If there is an increase in pH, these enteroliths can calcify8 and become radio-opaque, although this is an uncommon finding.5,8 False enteroliths generally form around a central nidus, such as a foreign body, faecolith or bezoar (poorly digested vegetable matter that appears on CT as a mottled-appearing mass containing air).4,5 Although enteroliths can arise de novo, other factors can contribute to their formation. These include injury to the bowel lumen (from inflammation, surgery and strictures), metabolic conditions and medications that cause hypomotility.4,7 It is hypothesized that the patient discussed in this case study had a false enterolith, which had formed around a bezoar, owing to its centrally gas-filled appearance on CT. Initially, conservative management with nasogastric tube decompression and intravenous fluids is often attempted but is usually unsuccessful.2,4,7,9,10 Thus, the definitive management of enterolith bowel obstruction is surgical. If the cause of the obstruction is unclear, a laparoscopy can be performed. However, the laparoscopic approach is not recommended for crushing or milking the enterolith
due to the risk of trauma to the oedematous bowel.4 Laparotomy is therefore recommended. The enteroliths may be crushed and then milked into the distal colon.4,5,8,9 An enterotomy can also be performed distal to the obstruction where the bowel is less oedematous, and the enterolith is removed through this incision, if it is not possible to crush the enterolith.2–9 If these last techniques are unsuccessful, or if there are any complications such as focal necrosis or diverticulitis, resection of the affected segment, along with the enterolith, may be required.2,9 It is also recommended to check all the diverticulae seen and to remove any further enteroliths that may be seen to avoid recurrence.4 Enteroliths are a rare cause of small bowel obstruction; however, they should be considered, particularly those with no previous history of abdominopelvic surgery. Imaging may show the enterolith itself, or may suggest it, by the presence of small bowel diverticulae. Conservative management may be attempted; however, it is usually unsuccessful and laparotomy is often needed to resolve the obstruction. A number of techniques can be used, including crushing of the enterolith, an enterotomy to remove the enterolith or bowel resection. Any other small bowel diverticulae seen at the time of the operation should also be inspected to ensure they are not harbouring any further enteroliths, which may cause a recurrence.
References 1. Noer T. Non-Meckelian diverticula of the small bowel. Acta Chir. Scand. 1960; 120: 175–9. 2. Garnet DJ, Scalcione LR, Barkan A et al. Enterolith ileus: liberated large jejuna diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis. Br. J. Radiol. 2011; 84: 154–7. 3. Kornprat P, Langner C, Mischinger HJ. Enterolithiasis in jejuna diverticulosis, a rare cause of obstruction of the small intestine: a case report. Wien. Klin. Wochenschr. 2005; 117: 297–9. 4. Monchal T, Hornez E, Bourgouin S et al. Enterolith ileus due to jejunal diverticulosis. Am. J. Surg. 2010; 199: 45–7. 5. Hayee B, Khan HN, Al-Mishlab ET. An unusual case of enterolith small bowel obstruction and jejunal diverticulosis. World J. Gastroenterol. 2003; 9: 833–4. 6. Crace PP, Grisham A, Kerlakian G. Jejunal diverticular disease with unborn enterolith presenting as a small bowel obstruction: a case report. Am. Surg. 2007; 73: 703–5.
© 2013 Royal Australasian College of Surgeons
Images for surgeons
7. Klingler PJ, Seelig MH, Floch NR, Branton SA, Metzger PP. Smallintestinal enteroliths – unusual cause of small-intestinal obstruction: report of three cases. Dis. Colon Rectum 1999; 42: 676–9. 8. Shocket E, Simon SA. Small bowel obstruction due to enterolith (bezoar) formed in a duodenal diverticulum: a case report and review of the literature. Am. J. Gastroenterol. 1982; 77: 621–4. 9. Steenvoorde P, Schaardenburgh P, Viersma JH. Enterolith ileus as a complication of jejunal diverticulosis: two case reports and a review of the literature. Dig. Surg. 2003; 20: 57–60.
691
10. Efremidou EI, Liratzopoulos N, Papageorgiou MS et al. Enterolith small-bowel obstruction caused by jeunal diverticulosis. Surg. Today 2006; 36: 1003–6.
Tam Quinn, MBBS, BMedSci, PGDipSurgAnat Paul Strauss, MBBS, FCS (SA) Department of General Surgery, Central Gippsland Health Service, Sale, Victoria, Australia doi: 10.1111/ans.12301
Pseudocysts secondary to retained gallstones post-laparoscopic cholecystectomy An 88-year-old gentleman was investigated for 6 weeks of rightsided abdominal and flank pain associated with bulging in the flank region. There were no associated constitutional symptoms such as fevers, sweats or reported weight loss. The patient was otherwise medically well and the only history of any real note was that of a laparoscopic cholecystectomy performed 12 years prior without apparent complication. Ultrasound examination and subsequent helical computerized tomography (CT) scanning with intravenous and oral contrast was performed. This demonstrated two cystic foci containing calcified material (Figs 1,2). The first measured 8 cm and was contained within Morrison’s pouch. This lesion was noted to be discharging into the adjacent intercostal space. The second lesion measuring 7 cm was noted medial to the caecum, centred on the small bowel mesentery. The initial suggestion from the radiologist was that these lesions were hydatid cysts. A trial of empirical treatment with albendazole was undertaken. Hydatid serology was performed and was negative. Other blood tests including C-reactive protein and white cell count were unremarkable. Surgical review was obtained and given the past history of cholecystectomy, and faceted appearance of the calcified areas within the lesions, it was
thought they were likely related to retained gallstones. The patient underwent a laparotomy and had complete excision of two cystic lesions, corresponding to the cystic foci on the CT scans. Retained gallstones were evident in both cavities (Fig. 3). Histopathology demonstrated thick fibrous walled lesions lined by florid xanthogranulomatous inflammation an appearance consistent with pseudocysts. Post-operatively, the patient recovered well with resolution of his symptoms of pain and a mass. The laparoscopic approach to cholecystectomy has become the method of choice, resulting in high rates of patient satisfaction and rapid recovery from surgery. However, compared with open surgery, there is an increased incidence of gallstone spillage and retrieval of spilt stones is more difficult in laparoscopic scenarios. The reported incidence of gallstone spillage in the literature for laparoscopic cholecystectomy varies widely, ranging from 6–30%.1–3 In most cases, gallstone spillage does not result in any adverse sequelae; however, it should be noted that complications can arise many years later as in this case. Overall, complications are estimated to occur in less than 1% of cases.4 The main complication that can occur is abscess formation around the stone, although other complications have been reported including enterocutaneous fistula formation, migration into the
Fig. 1. Coronal CT demonstrating cystic foci with calcified material.
Fig. 2. Axial CT demonstrating cystic foci with calcified material.
© 2013 Royal Australasian College of Surgeons
