LAUSR

A 71-year-old man presented with a 7-day history of increasingly severe colicky central abdominal pain, vomiting and obstipation. On examination, his abdomen was soft, non-tender and mildly distended. He had no significant medical or surgical history and lived independently. Plain abdominal X-rays revealed a single dilated loop of proximal small bowel. Electrocardiogram and erect chest X-ray were unremarkable. Laboratory findings demonstrated a modest inflammatory response (total white blood count (12.1 × 10) and C-reactive protein (36 mg/L)). The patient was placed nil by mouth, commenced on intravenous fluids and a nasogastric tube drained 2800 mL of bilious enteric fluid in 24 h. A double-contrast abdominal computed tomography (Fig. 1) displayed features of a small bowel obstruction secondary to the presence of a calcified intraluminal abnormality. In addition, a large jejunal diverticulum was noted (Fig. 2). Patient consent was obtained. A laparotomy was performed where a small bowel obstruction was confirmed. The site of obstruction was the proximal ileum due to an impacted calcified stone-like lesion measuring 45 × 34 × 30 mm (Fig. 3). The lesion was milked proximally before removal via a transverse enterotomy. A single large proximal jejunal diverticulum was identified within the mesentery but was not resected due to concern regarding the oedematous and distended nature of the bowel wall and potential risks inherent with proximal anastomoses of obstructed small bowel in an elderly patient. There was no other abnormality noted at laparotomy. Histopathological examination of the lesion confirmed it to be composed of calcified enteric debris consistent with an enterolith. The patient made an excellent recovery and was discharged home on the sixth post-operative day. Diverticula of the small bowel are classified as acquired false diverticulum (i.e. the mucosa and submucosa protrude through but not the muscularis propria). They occur at the site of entry of the mesenteric vessels and are thought to develop due to disordered motility and high intraluminal pressure. Jejunal diverticulosis is uncommon with an incidence of 0.06–1.3% in autopsy studies with older men being most affected. In this case, the enterolith formed within the bowel lumen (within the jejunal diverticulum) and thus was a primary enterolith.