P2433 - Afferent Limb Small Bowel Obstruction Secondary to Enterolithiasis After Afferent Limb Diverticulitis

Fangfang Wang, MD¹, Mashal Batheja, MD^2
1Mayo Clinic Arizona, Scottsdale, AZ; ²Mayo Clinic, Phoenix, AZ

Introduction: Enterolithiasis is a rare condition with serious complications. It can form in surgical enteroanastomoses, blind pouches, hernias, small intestinal tumors, inflammatory bowel disease strictures, and intestinal tuberculosis. Small bowel diverticulosis is a significant risk factor. Clinical presentation varies with enterolith location.

Case Description/Methods: A 75-year-old male with a complex medical and surgical history, including tubulovillous ampullary adenoma post-Whipple procedure (2010), gastrointestinal stromal tumor post-wedge resection (2019), and decompensated metabolic and alcohol-associated cirrhosis, was admitted for spontaneous bacterial peritonitis (SBP). During hospitalization, he reported right upper quadrant distention and pain. The patient had mild leukocytosis (10.2 x 10^9/L). A CT scan showed an enlarged jejunal diverticulum with a 3.7 cm food debris and mild fat stranding suggestive of diverticulitis. Endoscopic evaluation was deferred due to diverticulitis, and broad-spectrum antibiotics were recommended. After 14 days of intravenous antibiotics, he continued to have pain, fever, and severe abdominal distention. Leukocytosis worsened to 20.4 x 10^9/L. Repeat CT imaging showed migration of the enterolith into the bowel lumen, leading to high-grade small bowel obstruction (SBO) and fluid distention in the pancreaticobiliary limb above the gastrojejunal anastomosis, resulting in intra- and extra-hepatic biliary dilatation. Given his comorbidities and preferences, endoscopic therapy was recommended. Upper endoscopy revealed a large concretion in the afferent limb of the jejunum. The concretion was removed using a Roth net, TTS balloon extraction, and rat tooth forceps. Two small superficial ulcers were found near the gastrojejunostomy anastomosis, likely due to stasis from the concretion. A large diverticulum was found in the biliary jejunum limb. Post-procedure, his symptoms resolved, his diet was advanced to a low-residue diet, and he was discharged after two days.

Discussion: Small bowel obstruction due to an afferent limb enterolith is rare. Presentation can be nonspecific, insidious, and easily masked, especially in patients with other conditions. Small bowel diverticulosis/diverticulitis may be a risk factor and result from altered small bowel anatomy and motility post-surgery. Early recognition with imaging can improve outcomes. For non-surgical candidates, endoscopic therapy can be effective, though long-term effects are yet to be determined.



Disclosures:


Fangfang Wang, MD¹, Mashal Batheja, MD². P2433 - Afferent Limb Small Bowel Obstruction Secondary to Enterolithiasis After Afferent Limb Diverticulitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.