PMC8553354_01
Magnetic resonance imaging (MRI) findings.. a) Transverse plane. b) Frontal plane. MRI shows a 4.5-cm oval structure in the small intestine in the pelvis (white star). A stenosis of the small intestine was also detected via MRI with the thickening of the intestinal wall on the anal side of the oval structure (white arrowhead); however, there is no evidence of intestinal obstruction. There are no other abnormal findings on MRI.
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An MRI performed 1 month before surgery due to transient epigastric pain examination revealed a 4.5-cm-sized oval structure in the small intestine (Figure 1), which was later diagnosed as an enterolith. The MRI and additional computed tomography (CT) showed stenosis of the small intestine with the thickening of the intestinal wall just on the anal side of the enterolith without any evidence of intestinal obstruction (Figure 1).
Transanal double-balloon enteroscopy (DBE) findings.. a) Transanal DBE revealed mild stenosis with an ulcer in the jejunum, approximately 250 cm proximal to the terminal ileum. b) The enteroscope that was inserted through the stenotic site of the jejunum revealed a yellowish-brown oval enterolith on the oral side. Attempts to remove and crush the enterolith using biopsy forceps and snare forceps were unsuccessful. Removal of the enterolith by oral DBE was considered impossible because its large size made it difficult to grasp it securely with snare forceps and to pass it through the pylorus.
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Transanal DBE showed a stenotic site in the jejunum, located 250 cm from the terminal ileum (Figure 2a). The jejunal stenosis was mild enough for DBE to pass, with DBE revealing the presence of an enterolith on the oral side of the stenosis (Figure 2b). We failed to remove and crush the enterolith endoscopically (Figure 2b).
Intraoperative findings.. A stenotic site with thickening of the intestinal wall was found in the jejunum, approximately 150 cm distal to the Treitz ligament (black arrowhead). The hard oval enterolith on the oral side is guided to the stenotic site of the jejunum but cannot be moved to the anal side of the stenotic site (white star).
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The stenotic site was located in the jejunum, approximately 150 cm from the Treitz ligament, along with the enterolith (Figure 3).
Findings of the resected specimen.. a) Inflammatory changes in the intestinal mucosa, scarring, and thickening of the intestinal wall were macroscopically observed at the stenotic site of the jejunum, but no neoplastic lesions were detected. b) Histologically, a partial erosion was observed at the stenotic site of the jejunum, accompanied by the thickening of the mucosa and muscularis mucosae and fibrosis of the submucosa. There were no histological findings indicating malignancy.
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The stenotic site of the resected jejunum showed inflammation and fibrous changes without malignant findings (Figure 4).
Enterolith findings.. a) The enterolith, yellowish-brown in color, oval-shaped, and hard, with a maximum diameter of 4.5 cm. b) The cut surface is yellow and has a multilayered structure. c) Component analysis by infrared spectroscopy revealed that more than 98% of the enterolith is composed of ursodeoxycholic acid.
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The enterolith appeared yellowish-brown and oval with a diameter of 4.5 cm (Figure 5a). The cut surface was yellow and had a multilayered structure (Figure 5b). Subsequently, oral administration of UDCA was discontinued after surgery (Figure 5c).