A RARE CASE OF ACUTE SMALL BOWEL OBSTRUCTION SECONDARY TO TRUE PRIMARY ENTEROLITH

Background: Enterolithiasis also known as gastro-intestinal concretions are uncommon and are formed in the setting of intestinal stasis. Enteroliths are incidentally detected on imaging. Most enteroliths are asymptomatic, but they may rarely lead to bowel obstruction, haemorrhage and perforation. Clinical Presentation: We report a case of a lady in her 70s presented to surgery emergency with abdominal pain, distension, and constipation for 4 days. She had no history of abdominal surgery or foreign body ingestion. Abdominal examination revealed soft, distended abdomen with exaggerated bowel sounds. Abdominal X-ray revealed multiple air-fluid levels and dilated small bowel loops with a radio-opaque shadow in the pelvis. A contrast-enhanced computed tomography of abdomen showed a lamellated high density oval structure in the distal ileum measuring 3.7x2.8 cm with upstream dilatation of jejunal and ileal loops. No signs of pneumobilia or gallstones. Emergency exploratory laparotomy was done. Dense adhesions involving terminal ileum and omentum forming a mass in right iliac fossa with dilated proximal bowel. 4x4 cm impacted enterolith 20 cm proximal to ileo-caecal junction with significant thickening of bowel wall and luminal narrowing. Segmental resection of ileum and double barrel ileostomy was done. post operative period was uneventful and patient was discharged on post operative day 5. Histopathology report of resected bowel was suggestive of chronic inflammation. Conclusion: Enteroliths may be single or multiple and range in size from few millimetres to few centimetres. Small enteroliths causing partial bowel obstruction can be managed non operatively. Enterolith causing acute obstruction requires surgical intervention. Optimal treatment include milking into colon, enterotomy with enterolith removal and treatment of underlying pathology. Resection of involved segment is considered if associated with impaction and stricture.