Enterolithiasis complicating intestinal tuberculosis

Clin. Radiol. (1966) 17, 274-279

ENTEROLITHIASIS

COMPLICATING

INTESTINAL

TUBERCULOSIS

S. CHAWLA, K. BERY and K. J. I N D R A

From the Department of Radiology, Lady Hardinge Medical College and Hospital, New Dehli, lndia Intestinal tuberculosis occurs frequently in India. Of more than 400 patients with tuberculous enterocolitis, seen in a 5 year period, 13 patients had radio-opaque calculi in the bowel proximal to a tuberculous obstruction. The calculi were found in the lower ileum or colon: they varied considerably in shape, size, radio-opacity and number. The authors present the clinical, radiological and operative findings of these 13 patients and discuss the aetiology and differential diagnosis of enteroliths.

ENTEROLITHIASISis a rare entity and usually occurs as a result of stasis in the intestinal tract. Stasis can occur in an interstinal diverticulum or proximal to a stenosing lesion. Enteroliths in duodenal and jejunal diverticula have been reported by HellstrSm (1929), Shaw (1940), Ward-Mcquaid & Gordon (1950), Slater (1953), Blair (1959), Atwell & Pollock (1960) and Walker, Kerr & Macdonald (1960). Enteroliths proximal to intestinal stricture have been reported by Phillips (1921), HellstrSm (1929), Kelly (1932), Blix (1935), Richards (1951), Fow weather (1955) and Atwell & Pollock (1960). These stenosing lesions were of varied etiology such as Crohn's disease, malignancy, tuberculosis or as a result of previous surgery. A review of the radiological literature did not reveal any reference

to enteroliths complicating tuberculous strictures except for 2 cases previously reported (Bery, Virmani & Chawla, 1964). Since the pre-operative diagnosis can only be made radiologically, we have reported this group which is probably the largest single series in which the enteroliths were associated with distal tuberculous intestinal strictures. Over a period of 5 years, tubercular enterocolitis was diagnosed radiologically in over 400 patients. Most of these were confirmed by surgery and histopathology. Amongst these there were 13 cases of enterolithiasis, an incidence of 3-25% (Table 1). The radiological investigations carried out included chest x-ray, plain x-ray of the abdomen, barium meal and barium enema examinations. Sometimes excretory pyelographic studies and cholecystography were also performed.

FIG. I FIG. 2 F~G. 3 FIG. 1.--Case 3. Plain abdominal x-ray, showing multiple pelvic opacities and a grossly dilated intestinal loop. FIG. 2.--Case 3. Barium meal follow-through, showing dilated loop of terminal ileum, continuous with the hepatic flexure. FIG. 3.--Case 3. Radiograph of surgical specimen showing multiple enteroliths in the dilated ileal loop.

274

ENTEROLITHIASIS

COMPLICATING

INTESTINAL

TUBERCULOSIS °

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CLINICAL

RADIOLOGY

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E N T E R O L I T H I A S I S C O M P L I C A T I N G I N T E S T I N A L TUBERCULOSIS TABLE 2 SITE OF THE TUBERCULOUSLESION IN 13 CASES OF ENTEROL1THIASIS

Ileum

2

lleo-caecal region

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Ileum and Ileo-caecal region

4

Transverse colon

2

Ileo-caecal region and pro×imal transverse colon

1

I!eo-caecal region and colon up to descending colon 1

Illustrative Case Histories.--Case 3.--Female aged 24, admitted with abdominal pain and post-prandial distension for 9 years. On examination there were marked peristalsis and palpable loops of intestines. Chest x-ray showed no abnormality. Plain x-ray examination of the abdomen showed multiple opacities of varying shapes and sizes lying in the pelvis. A grossly dilated intestinal loop full of faecal matter was seen in the right side of the abdomen. (Fig. 1). A barium meal showed a grossly dilated loop of terminal ileum which was pulled up and continuous with the hepatic flexure. The caecum and ascending colon were skipped (Fig. 2). At operation, the .hypertrophied, grossly dilated, loop of terminal ileum was resected along with the right half of the colon. A radiograph of the surgical specimen showed the dilated ileal loop containing multiple enteroliths (Fig. 3). Case 7. Female aged 40, admitted with abdominal pain, indigestion, weight loss and vomiting for one year. There was a palpable, ill defined mass, 8 cm. × 8 cm. in the umbilical region and the caecum was palpable. Chest x-ray showed calcified left paratracheal and hilar lymph nodes, but no active tuberculous lesion was seen. Plain x-ray of the abdomen showed multiple ring shaped opacities in the right iliac fossa and the right lumbar region. A barium meal follow-

277

through showed a stricture at the transverse colon with dilatation of the proximal colon.(Fig. 4). At operation, there was a narrow stricture of the proximal transverse colon with a dilated ascending colon containing enteroliths. A right bemi-colectomy was performed. X-ray examination of the surgical specimen showed a dilated, ascending colon, with enteroliths and a stricture of the proximal transverse colon (Fig. 5). Case l l . - - F e m a l e aged 35, complaining of abdominal pain for 4 years and low grade fever and cough for 3 months. An ileo-caecal mass was palpable. Plain x-ray of the abdomen showed 2 opacities, one in the right pelvis and the other 3 cm. above the right iliac crest (Fig. 6). A barium enema, post evacuation film, showed a dilated terminal ileum continuous with a shortened ascending colon. The caecum was skipped. The radiological appear ances were consistent with ileo-caecal and ascending colon lesions (Fig. 7). At surgery, the caecum, ascending and proximal transverse colon were thickened forming a mass. The terminal ileum was dilated and there was a tight stricture in the mid transverse colon. Sub-total colectomy was carried out. Radiographs of the surgical specimen showing two enteroliths, one in the terminal ileum and the other in the ascending colon (Fig. 8). Case 13.-- Female aged 35, admitted with pain and a progressive swelling of the right lumbar region. A tender mass was bimanually palpable in the right lumbar region, which was thought to be renal in origin. Chest x-ray was normal and a plain abdominal x-ray showed a single, large, lamellated calculus in the right lower abdomen. A lateral view showed the calculus to be lying anteriorly and a large gall stone or a renal stone in a hydronephrotic sac were considered to be the most probable diagnoses. However, intravenous pyelography showed normal excretory pyelographic appearances with the calculus lying outside the renal collecting system (Fig. 9) and a barium enema showed a long narrow stricture involving the descending colon near the splenic flexure beyond which the barium could not pass (Fig. 10). At this stage, a diagnosis of an enterolith proximal to a steuosing lesion was made.

FIG. 4 Fro. 5 FiG. 4.--Case 7. Barium meal follow-through, showing stricture at the transverse colon, with dilatation of proximal colon. FIG. 5.--Case 7. Radiograph of surgical specimen, showing euteroliths in dilated ascending colon and stricture of transverse colon.

278

CLINICAL

FIG. 6

RADIOLOGY

FIG. 7

FIG. 6.--Case 11. Plain abdominal x-ray, showing 2 opacities. FIG. 7.--Case 11. Barium enema, post-evacuation, showing dilated terminal ileum and shortened ascending colon. FIG. 8.--Case 11. Two radiographs of surgical specimen, showing 2 enteroliths, in the terminal ileum and the ascending colon.

FIG. 9

FIG. 10

FIG. 9.--Case 13. Intravenous pyelogram, showing calculus outside normal renal collecting system. FIG. 10.--Case 13. Barium enema showing long narrow stricture near splenic flexure, beyond which barium would not pass.

At operation, the terminal ileum was dilated and contained a large calculus. The caecum and ascending and transverse colon, up to the stricture, were contracted and formed a mass. Sub-total colectomy was performed. DISCUSSION M o s t foreign bodies pass with ease t h r o u g h the a l i m e n t a r y canal unless there is mechanical obstruc-

tion. Mechanical obstruction in the small or large bowel m a y be caused by tuberculous strictures, ileo-caecal tuberculosis, C r o h n ' s disease or previous surgery. Blix (1935) a n d Atwell & P o l l o c k (1960) consider t h a t a stricture or a diverticulum o f the small intestine is necessary for f o r m a t i o n o f stones. This mechanical d e r a n g e m e n t e n c o u r a g e s the a c c u m u l a t i o n o f precipitated substances o n t o the

E N T E R O L I T H I A S I S C O M P L I C A T I N G I N T E S T I N A L TUBERCULOSIS

ingested foreign body. For example, fruit skin or seeds may form the nidus for the deposition of salts. The demonstration of intestinal calculi by x-rays depends on their chemical composition, which is related to the site of their formation. Enteroliths which are formed high u p in the intestine are nonopaque as they contain mainly choleic acid, but enteroliths formed at lower levels contain mainly calcium salts and hence are radio-opaque. This is explained by the fact that the calcium salts are more soluble in alkaline media of the distal ileum and the colon. The enteroliths seen in the present series were found in the ileum or proximal colon. All were radio-opaque, varying in appearance from thin curvilinear ring shaped shadows with translucent centres (Case 7), to uniformly dense opacities (Case 11) and large lamellated calculi (Case 13). In Case 10, plain x-ray of the abdomen was not performed and the single enterolith was missed on the barium study, but radiographs of the surgical specimen showed the enterolith to be a faintly calcified oval opacity, with a radio-lucent centre. In all our patients, mechanical obstruction was caused by intestinal tuberculosis. The associated pulmonary tubercular lesion was not of much help in establishing the diagnosis, as only 2 of the 13 patients had active pulmonary tuberculosis and only 3 showed calcified intrathoracic lymph nodes or lung loci. Intestinal tuberculosis is a major problem in countries such as India where tuberculosis is common, unlike the Western countries where it has been mostly eradicated. In the Lady Hardinge Medical College and Hospital, which mainly serves women patients from lower social strata, about 15 of all barium studies carried out in the Radiology Department show appearances consistent with tuberculosis. Many of these are confirmed at operation. Complications of intestinal tuberculosis like obstruction and perforation have been well documented, but very little emphasis has been placed on the occurrence of enterolithiasis in intestinal tuberculosis. Of 400 consecutive cases of intestinal tuberculosis studied over the last 5 years, we have found 13 where intestinal calculi were associated with distal tubercular strictures. Twelve of the 13 patients underwent surgery and the diagnosis of tuberculosis was confirmed by histological evidence of tuberculosis either in the bowel wall or in a mesenteric lymph node. In Case 2, the stool culture

279

was positive for Acid Fast Bacilli. This patient refused surgery and is responding well to antituberculous treatment. In all the operated patients, the gall bladders and bile ducts were normal. The size and shape of the enteroliths vary in the same patient and they may be single or multiple. In Case 3, there were 82 enteroliths of different sizes and shapes and of varying radiographic densities. The largest number of enteroliths (1400) in one patient was reported by Winterstein (1925). These had formed proximal to a carcinoma of colon. There have been 2 previous single case reports from India by Taneja (1960) and Prakash, Bapna, Rao & Chawla (1963). In both, there was a single radioopaque enterolith in the ileum, associated with distal tubercular stricture. Enteroliths must be differentiated radiologically from vesical calculi, gall stones and renal calculi, depending upon their site, number and radiological appearances and pyelography and cholecystography may be necessary. Confirmatory radiological evidence is obtained if the opaque shadows can be shown to move over a large area in serial films as only intestinal calculi are capable of such mobility. Barium studies may show filling defects in the small or large bowel and may reveal a stricture distal to the enteroliths. Since an obstruction is present, most of these patients require surgery.

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WALK~R, W. F., KFRR, G. & MACDONALD, J. S. (1960). Brit. J. Surg., 48, 143. WARD-McQuAID, J. N. & GOrtDON,E. G. (1950). Brit. J. Surg., 38, 109. W~Na-ERST~IN,O. (1925). Dtsch. Z. Chir., 193,409. Cited by O. H. Wangensteen (1955). Intestinal Obstructions, 3rd Edition. Springfield, Ill. : C. C. Thomas.