European Journal of Radiology, 10 ( 1990) 154-l 55
Elsevier
154
EURRAD
00025
An unusual case of obstruction of the colon Khanh T. Nguyen ‘, Ken Mackie’ and Ken Taguchi2 Departments of ‘Radiology and 2Surgery, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
(Received
10 October
1989; accepted 5 November
Key words: Ileus, radiography;
Obstruction,
1989)
colon
Case report A 74-year-old male was admitted to hospital complaining of increasing crampy pain on the left side of the upper abdomen and failure to pass gas and stools per rectum for 5 days. The history includes surgical repair of an inguinal hernia 2 years previously. On sonography at that time gallstones were reported. Physical examination and laboratory tests on the present admission were unremarkable. Radiography of the abdomen
suggested distal colonic obstruction. There was a small irregular collection of gas related to the hepatic flexure (Fig. la), which was thought to be of no significance. Flexible sigmoidoscopy revealed the obstructing lesion at 40 cm, which was thought to be a large enterolith. Attempts to extract the enterolith with a snare were not successful. A barium enema was then performed (Fig. lb), followed by surgery.
Fig. 1. (a) Supine film of the right upper abdomen. There is an irregular collection of gas (arrow) adjacent to the hepatic flexure. (b) Single contrast barium film, showing a large lucent area in the splenic flexure (arrow) obstructing the descending colon. (c) Double contrast barium study performed 2 weeks after surgery, shows a fistulous tract arising from the hepatic flexure.
Address for reprints: K.T. Nguyen, Kingston, Ontario, Canada K7L 2V7. 0720-048X/90/$03.50
M.D.,
Diagnostic
0 1990 Elsevier Science Publishers
Radiology
Department,
B.V. (Biomedical
Division)
Kingston
General
Hospital,
76 Stuart
Street,
155
Diagnosis: gallstone obstructing the distal colon At laparotomy a large gallstone, measuring 4 cm in maximum diameter was milked from the descending colon into the rectum and extracted manually. A barium enema 2 weeks later demonstrated a fistulous tract (Fig. lc) from the hepatic flexure, corresponding to the irregular collection of air seen on Fig. la. Discussion Since the first description by Bartholini in 1954, gallstone ileus remains a continuing surgical problem [ 11. Most gallstones eroding through the gallbladder wall into the gastrointestinal tract do not cause bowel obstruction. If obstruction occurs, this is usually at the terminal ileum and jejunum, in that order, and is usually caused by gallstones larger than 2.5 cm [2,3]. Colonic obstruction is rare, but may happen if the stone is too large or if the colon is narrowed by a benign or malignant structure. The radiology of gallstone obstruction has been well described in the literature. The manifestations include: air in the biliary tree, signs of small bowel obstruction, presence of a stone in the bowel, and change in the position of a gallstone, previously visualized. However, preoperative diagnosis is usually made in only 64% of cases [ 3,4]. There are three interesting radiological features with regard to this patient. Firstly, careful analysis of the abdominal films on admission could have given a clue
to the diagnosis. This is true for most of the cases of suspected gallstone ileus. The small irregular collection of gas was in fact in the fistulous tract between the gallbladder and hepatic flexure and not in the biliary tree. Secondly, the obstruction occurred in the colon and not in the small bowel. This is related to the large size of the gallstone, which perforated directly into the hepatic flexure. Thirdly, one should also consider obstruction by endogenous enterolithiasis, which is stone formation in the intestinal tract and mostly due to faecal stasis [5,6].
Acknowledgement We wish to thank Miss Yvonne DeRoche for typing the manuscript.
References Hudspeth AS, McGuirt WF. Gallstone ileus: a continuing surgical problem. Arch Surg 1970; 100: 668-672. Kasahara Y, Umemuira H, Shiraha S, et al. Review of the 112 patients in the Japanese literature. Am J Surg 1980; 180: 437-440. Syme RG. Management of gallstone ileus. J Can Surg 1989; 32: 61-64. Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941; 117: 1753-1759. Javors BR, Bryk D. Enterolithiasis: a report of four cases. Gastrointest Radio1 1983; 8: 359-362. Lebolt SA, Turner MA. Enterolithiasis as a cause of intestinal obstruction. J Can A Rad 1989; 40: 119-120.
Elsevier
154
EURRAD
00025
An unusual case of obstruction of the colon Khanh T. Nguyen ‘, Ken Mackie’ and Ken Taguchi2 Departments of ‘Radiology and 2Surgery, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
(Received
10 October
1989; accepted 5 November
Key words: Ileus, radiography;
Obstruction,
1989)
colon
Case report A 74-year-old male was admitted to hospital complaining of increasing crampy pain on the left side of the upper abdomen and failure to pass gas and stools per rectum for 5 days. The history includes surgical repair of an inguinal hernia 2 years previously. On sonography at that time gallstones were reported. Physical examination and laboratory tests on the present admission were unremarkable. Radiography of the abdomen
suggested distal colonic obstruction. There was a small irregular collection of gas related to the hepatic flexure (Fig. la), which was thought to be of no significance. Flexible sigmoidoscopy revealed the obstructing lesion at 40 cm, which was thought to be a large enterolith. Attempts to extract the enterolith with a snare were not successful. A barium enema was then performed (Fig. lb), followed by surgery.
Fig. 1. (a) Supine film of the right upper abdomen. There is an irregular collection of gas (arrow) adjacent to the hepatic flexure. (b) Single contrast barium film, showing a large lucent area in the splenic flexure (arrow) obstructing the descending colon. (c) Double contrast barium study performed 2 weeks after surgery, shows a fistulous tract arising from the hepatic flexure.
Address for reprints: K.T. Nguyen, Kingston, Ontario, Canada K7L 2V7. 0720-048X/90/$03.50
M.D.,
Diagnostic
0 1990 Elsevier Science Publishers
Radiology
Department,
B.V. (Biomedical
Division)
Kingston
General
Hospital,
76 Stuart
Street,
155
Diagnosis: gallstone obstructing the distal colon At laparotomy a large gallstone, measuring 4 cm in maximum diameter was milked from the descending colon into the rectum and extracted manually. A barium enema 2 weeks later demonstrated a fistulous tract (Fig. lc) from the hepatic flexure, corresponding to the irregular collection of air seen on Fig. la. Discussion Since the first description by Bartholini in 1954, gallstone ileus remains a continuing surgical problem [ 11. Most gallstones eroding through the gallbladder wall into the gastrointestinal tract do not cause bowel obstruction. If obstruction occurs, this is usually at the terminal ileum and jejunum, in that order, and is usually caused by gallstones larger than 2.5 cm [2,3]. Colonic obstruction is rare, but may happen if the stone is too large or if the colon is narrowed by a benign or malignant structure. The radiology of gallstone obstruction has been well described in the literature. The manifestations include: air in the biliary tree, signs of small bowel obstruction, presence of a stone in the bowel, and change in the position of a gallstone, previously visualized. However, preoperative diagnosis is usually made in only 64% of cases [ 3,4]. There are three interesting radiological features with regard to this patient. Firstly, careful analysis of the abdominal films on admission could have given a clue
to the diagnosis. This is true for most of the cases of suspected gallstone ileus. The small irregular collection of gas was in fact in the fistulous tract between the gallbladder and hepatic flexure and not in the biliary tree. Secondly, the obstruction occurred in the colon and not in the small bowel. This is related to the large size of the gallstone, which perforated directly into the hepatic flexure. Thirdly, one should also consider obstruction by endogenous enterolithiasis, which is stone formation in the intestinal tract and mostly due to faecal stasis [5,6].
Acknowledgement We wish to thank Miss Yvonne DeRoche for typing the manuscript.
References Hudspeth AS, McGuirt WF. Gallstone ileus: a continuing surgical problem. Arch Surg 1970; 100: 668-672. Kasahara Y, Umemuira H, Shiraha S, et al. Review of the 112 patients in the Japanese literature. Am J Surg 1980; 180: 437-440. Syme RG. Management of gallstone ileus. J Can Surg 1989; 32: 61-64. Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941; 117: 1753-1759. Javors BR, Bryk D. Enterolithiasis: a report of four cases. Gastrointest Radio1 1983; 8: 359-362. Lebolt SA, Turner MA. Enterolithiasis as a cause of intestinal obstruction. J Can A Rad 1989; 40: 119-120.
