Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

LETTER TO EDITOR
Year
: 2002  |  Volume : 12  |  Issue : 1  |  Page : 135--136

Enteroliths


BRS Raidu, S Patnaik, CLV Rao 
 201, Park View Apartments, Humayun Nagar, Masab Tank, Hyderabad-500028, India

Correspondence Address:
BRS Raidu
201, Park View Apartments, Humayun Nagar, Masab Tank, Hyderabad-500028
India




How to cite this article:
Raidu B, Patnaik S, Rao C. Enteroliths.Indian J Radiol Imaging 2002;12:135-136


How to cite this URL:
Raidu B, Patnaik S, Rao C. Enteroliths. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Oct 21 ];12:135-136
Available from: http://www.ijri.org/text.asp?2002/12/1/135/28434


Full Text

Sir,

Though tuberculosis is a common cause for intestinal strictures in India, the incidence of associated enteroliths as reported in the literature, is very low[1]. The few reports of enteroliths in association with intestinal tuberculosis or other congenital/acquired causes were mainly from the northern and western parts of India[1,2,3]. Recently a 50-year-old female, who was treated for pulmonary tuberculosis 12 years back, presented to us with recurrent abdominal pain over the last two years. She had symptomatic treatment with antacids, anti-spasmodics and deworming agents. She was never thoroughly investigated or had any prior surgery. Clinical examination revealed nutritional debility and signs of sub-acute small intestinal obstruction. She was mildly pale but vital signs were stable. Hematological investigations were within normal limits, but for mild anaemia and raised ESR (40 mmHg 1st hour). All biochemical parameters were normal. An anteroposterior radiograph of the abdomen revealed multiple radio-opaque shadows of various shapes (round, oval or rectangular) in the pelvic region [Figure 1]a. Each of these shadows showed a peripheral dense rim with a central less dense area giving a laminated appearance [Figure 1]b. Chest X-ray revealed fibrocalcific shadows in the left apex, suggestive of old healed pulmonary tuberculosis. On laparotomy a stricture was detected in the terminal ileum with proximal dilatation. Thirty-three enteroliths of various sizes were present in the dilated ileal segment and a solitary one in the caecum [Figure 2]. All the enteroliths were removed; the strictures segment resected and end-to end anastomosis was done. Histopathology revealed chronic inflammatory pathology suggestive of tuberculosis.

When the plain abdominal radiograph shows multiple radio-opaque shadows of various shapes (pval, round or rectangular) with a pale core and a dense rim around, especially in an adult with chronic abdominal symptoms, enteroliths are a strong diagnostic possibility. Bery et al, in their report of 67 cases of enteroliths in tuberculosis of the intestines, described several radiological features; the most important ones being - typical dense rim and pale core of oval, round or rectangular shadows; 'Coin-end-on' appearance of the shadows; wide mobility of radio-opaque shadows in relation to the fixed structures in successive plain radiographs of abdomen or wide separation in one and closeting together in other radiographs. All these features were observed in our case [Figure 1]a&b. Uncommonly, other odd shapes are also encountered. Multiple gallstones, urinary stones or multiple calcified lymph nodes, teratoma of the mesentery and mesenteric fat necrosis are important entities in the differential diagnosis[5]. Enterolithiasis, the formation of small intestinal calculi, primarily in the gastro-intestinal tract is due to intestinal stasis. Meckel or non-Meckel's diverticulae and congenital / acquired strictures (intestinal tuberculosis, Crohn' disease, carcinoid tumor, post-traumatic or post-surgical strictures) are some of the most important underlying etiologies. Enteroliths are a result of sub-acute or chronic intestinal obstruction rather than a cause for obstruction. Duodenal and jejunal enteroliths often form in acidic medium and are generally non-radio opaque. The lower part of the small intestine being alkaline is conducive to the precipitation of calcium and hence enteroliths in this location are radio-opaque. Often these enteroliths have a nidus of bacterial or cellular debris or a fruit-stone. Sub-acute or chronic intestinal obstruction due to tuberculosis is expected to provide ideal conditions for 'enterolith' formation. But surprisingly its occurrence seems to be very rare. Prakash, in his review of intestinal tuberculosis over a period of 18 years, did not come across a single case of enterolith[4]. Deka found only one case among 230 cases of intestinal tuberculosis[1]. Low dietary calcium intake by tuberculosis patients in India or high phytate content in their diets (excreting calcium phytate) may be a possible explanation for the low incidence of enteroliths in them. Comparatively lower intake of milk and milk products by south Indians may also explain the extreme rarity of enteroliths in the southern states[1]. In the West, where TB is rare, the common underlying pathology is either Meckel's or other diverticulae. In our case, the history, chest X-ray, surgical findings and histopathology proved tuberculous stricture as the offending cause for the formation of enteroliths. Enteroliths are of significance as they lead us to the diagnosis of the underlying surgical ailment. Due to their rarity they may be misdiagnosed, unless the possibility is kept in mind. To the best of our knowledge this is the first report of this nature from Southern India.

References

1Bery K, Chawla S., Gupta S.K.: Enteroliths and Intestinal Tuberculosis. Ind J Radiol Imag, 1985; 39: 225-230.
2Bhaduri SB., Grover YK, Kashyap I.J: Multiple Intestinal Calculi. Ind J Radiol Imag, 1985; 39: 253-254.
3Gupta SK, Sharma OP., Agrawal AK, Singh AK, Sasibabu K: Enteroliths in Tuberculosis Strictures of Intestines. Ind J Gast 1984; 3: 89-91.
4Prakash A: Intestinal Tuberculosis - 18years review. Ind J Surg 1978; 40: 56-64.
5Van E. HW, Sybrandy R: Case 19: Enteroliths in a Meckel's diverculae. Radiology