(Radiology. 2000;214:524-526.)
© RSNA, 2000
Case 19: Enteroliths in a Meckel Diverticulum1
H. Wouter van Es, MD, PhD and
Rienk Sybrandy, MD, PhD
1 From the Departments of Radiology (H.W.v.E.) and Surgery (R.S.), St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands. Received September 17, 1998; revision requested November 12; revision received December 28; accepted February 17, 1999. Address reprint requests to H.W.v.E.
Index terms: Diagnosis Please • Intestines, calculi, 74.811 • Intestines, CT, 74.12112 • Intestines, diverticula, 74.1493
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HISTORY
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The patient is a 48-year-old man who was referred to the radiology department by his general practitioner for radiography of his sacrum and coccyx because of coccygodynia. The patient was otherwise healthy and did not have any abdominal complaints. There was no history of prior abdominal surgery.
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IMAGING FINDINGS
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An anteroposterior radiograph of the sacrum and coccyx showed as an incidental finding multiple stones in the right lower abdomen (Fig 1). The stones had peripheral calcifications and a radiolucent center. Contrast material–enhanced CT scans showed multiple calculi surrounded by soft tissues located within the mesenteric fat (Fig 2). A connection with a small-bowel loop was noted (Fig 2c, 2d). At surgery, a narrow-necked Meckel diverticulum (Fig 3) with multiple enteroliths (Fig 4) was found. Histopathologic examination of the Meckel diverticulum showed normal small-bowel mucosa.
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Figure 1. Anteroposterior radiograph of the sacrum and coccyx shows multiple stones (arrows) in the right lower quadrant with peripheral calcifications and a radiolucent center.
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Figure 2a. Transverse contrast-enhanced CT images of the lower abdomen with (a, c) narrow and (b, d) wide window settings. A mass (arrow in a) with soft-tissue attenuation reflective of bowel within the mesenteric fat surrounds the enteroliths (arrow in b). A narrow connection with the small bowel is seen (arrow in c, d).
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Figure 2b. Transverse contrast-enhanced CT images of the lower abdomen with (a, c) narrow and (b, d) wide window settings. A mass (arrow in a) with soft-tissue attenuation reflective of bowel within the mesenteric fat surrounds the enteroliths (arrow in b). A narrow connection with the small bowel is seen (arrow in c, d).
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Figure 2c. Transverse contrast-enhanced CT images of the lower abdomen with (a, c) narrow and (b, d) wide window settings. A mass (arrow in a) with soft-tissue attenuation reflective of bowel within the mesenteric fat surrounds the enteroliths (arrow in b). A narrow connection with the small bowel is seen (arrow in c, d).
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Figure 2d. Transverse contrast-enhanced CT images of the lower abdomen with (a, c) narrow and (b, d) wide window settings. A mass (arrow in a) with soft-tissue attenuation reflective of bowel within the mesenteric fat surrounds the enteroliths (arrow in b). A narrow connection with the small bowel is seen (arrow in c, d).
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Figure 3. Photograph obtained during surgery shows a Meckel diverticulum (arrow) with a narrow neck (small arrowhead) that connects the diverticulum to the small bowel (large arrowhead).
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Figure 4. Photograph of the multiple stones (arrows) found in the opened Meckel diverticulum (arrowhead).
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DISCUSSION
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The differential diagnosis of the calcifications at abdominal radiography includes biliary and urinary calculi, calcified lymph nodes, teratoma of the mesentery, mesenteric fat necrosis, and enteroliths. In this case, the differential diagnosis can be shortened to enterolithiasis of the small bowel because the appearance of the calcifications suggests enterolith formation in an area of stasis (1), and CT demonstrates that the calcifications are within a structure connected to small bowel. Stasis occurs in diverticula and above strictures. Enterolith formation in a blind pouch after a side-to-side enteroanastomosis has been described (2). Urinary calculi in an ileal conduit might also be considered. These possibilities are excluded, as this patient has not undergone any prior abdominal surgery. Enterolith formation in an area of dilated, chronically obstructed small bowel above a site of stricture can occur in Crohn disease or tuberculosis. The absence of distended bowel loops and associated chronic inflammatory changes excludes these diagnoses.
In the small bowel, a Meckel diverticulum is the most common site of enterolith formation, which is a rare complication of this diverticulum. Enteroliths in a Meckel diverticulum usually are triangular and flat and have a radiolucent center (1). The calcified structures can be misinterpreted as teethlike calcifications, which suggest the diagnosis of teratoma (3). Mesenteric teratomas are extremely rare and usually occur in children (4). In this case, a teratoma is ruled out because the mass around the calcifications is connected to small bowel and does not contain material of fatty attenuation, and the shape of the calcifications is not typical of dental or bone growth (5).
Meckel diverticulum is the most common congenital anomaly of the small bowel, with a prevalence of approximately 2% (6,7). It usually is located approximately 50 cm proximal to the ileocecal valve on the antimesenteric border. Meckel diverticulum has been calculated to have a 4.2% likelihood of becoming symptomatic during a lifetime (6). Complications consist of hemorrhage, intussusception, small-bowel obstruction, inflammation, perforation, neoplasm, and stone formation (6,8–10).
Enteroliths in a Meckel diverticulum are very rare. Authors of one study (10) reviewed the records of 776 patients with Meckel diverticulum and found stones in only two patients. The Armed Forces Institute of Pathology reported a much higher incidence—eight of 84 cases in 24 years contained stones (11). The pathogenesis of the stone formation is not clear. It has been suggested that a narrow neck, which was present in this case, can lead to stasis of intestinal contents in the diverticulum and subsequent enterolith formation (5,11). Enterolith formation occurs primarily in Meckel diverticula without ectopic gastric mucosa, which leads to an alkaline environment favoring the precipitation of calcium salts (11,12). Symptoms can be intermittent or acute abdominal pain (11,13,14). Complications consist of small-bowel obstruction by extrusion of a stone in the small-bowel lumen (11) and acute abdomen due to diverticulitis and perforation (12,13).
After surgery, the coccygodynia disappeared; however, a relationship between the symptoms and the enteroliths in the Meckel diverticulum is uncertain.
Our congratulations to the 52 individuals who submitted the most likely diagnosis (enteroliths in a Meckel diverticulum) for Diagnosis Please, Case 19. Credit was given if there was mention of Meckel diverticulum. The names and locations of the individuals, as submitted, are as follows:
- Gholamali Afshang, MD, Tinley Park, Ill
- Roger Antonelli, MD, Dayton, Ohio
- Lionel Arrivé, MD, Paris, France
- Edward L. Baker, MD, San Francisco, Calif
- Barbara Biber, MD, Portland, Me
- Jeffrey Black, Lafayette, Calif
- Eric L. Bressler, MD, Minnetonka, Minn
- Michael P. Buetow, MD, Okemos, Mich
- Antoine Charachon, Paris, France
- Royce A. Chrys, MD, Oakland, Calif
- Holt Daniel, Fort Worth, Tex
- M. G. de Baets, MD, Lugano, Switzerland
- Olivier Dourthe, MD, Sophia Antipolis, France
- Seyed A. Emamian, MD, PhD, Washington, DC
- Keith D. Epperson, MD, Milwaukee, Wis
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Burton Gold, MD, Mineola, NY
- Bhaskar Golla, Floral Park, NY
- Herbert F. Gramm, MD, Boston, Mass
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Rufus W. Head, MD, North Bridgton, Me
- Douglas S. Katz, MD, Mineola, NY
- Richard Krauthamer, MD, Rolling Hills, Calif
- Alan Laorr, MD, Eden Prairie, Minn
- N. B. S. Mani, MD, Chandigarh, India
- Manabu Minami, MD, Tokyo, Japan
- Robert E. Mindelzun, MD, Stanford, Calif
- Peter Mollet, MD, Gent, Belgium
- Eduardo Mondello, Buenos Aires, Argentina
- Douglas Moote, London, Ontario, Canada
- Dr. K. Mortele, Gent, Belgium
- Gianfranco Nicoli, MD, Locarno, Switzerland
- Ann B. Owen, MD, Murfreesboro, Tenn
- Frederick J. Phillips, MD, Soltau, Germany
- John M. Plotke, Naperville, Ill
- M. R. Ramakrishnan, MD, Big Stone Gap, VA
- Julio Saenz de Ormijana, MD, Vitoria, Spain
- Pierre-Jean Sauvage, Mâcon, France
- Arnold Schmid, Neuss, Germany
- Raymond Selouan, MD, Beirut, Lebanon
- Matt Shapiro, MD, Lowell, Mass
- Dr. R. Sinha, Patna, India
- Paolo Siotto, MD, Cagliari, Italy
- Marius Stellmann, MD, Scheessel, Germany
- Stacy Stevens, MD, San Antonio, Tex
- Douglas L. Teich, MD, Brookline, Mass
- Jorgelina Trepat, MD, Rosario, Argentina
- Gustavo Triana, MD, Santafe de Bogota, Colombia
- Ronald Wachsberg, MD, Newark, NJ
- David J. Wright, MD, Lake Oswego, Ore
- Joe Yut, Olathe, Kan
- Domenic Zambuto, MD, North Andover, Mass
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TOP
HISTORY
IMAGING FINDINGS
