Enterolith
Encyclopedia
An enterolith is a mineral concretion
or calculus
formed anywhere in the gastrointestinal system. Enteroliths are uncommon and usually incidental findings but, once found, they require at a minimum watchful waiting
. If there is evidence of complications, they must be removed.
An enterolith may form around a nidus, a small foreign object such as a seed, pebble, or piece of twine, that serves as an irritant. In this respect, an enterolith forms by a process similar to the creation of a pearl.
An enterolith is not to be confused with a gastrolith
, which helps digestion.
. Therefore, the incidence of asymptomatic enteroliths is unknown.
Equine enteroliths typically are smoothly spherical or tetrahedral, consist mostly of the mineral struvite
(ammonium
magnesium
phosphate
), and have concentric rings of mineral precipitated around a nidus.
Enteroliths in horse
s were reported widely in the 19th century, infrequently in the early 20th century, and now increasingly. They have also been reported in zebra
s: five in a zoo
in California
and one in a zoo in Wisconsin
. Struvite enteroliths are associated with elevated pH
and mineral concentrations in the lumen. In California
, struvite enteroliths are associated also with a high proportion of alfalfa
in the feed and less access to grass pasture. This association has been attributed to the cultivation of alfalfa on serpentine soil
s, resulting in high concentrations of magnesium
in the alfalfa.
s, enteroliths are rare and may be difficult to distinguish from gall stones. Their chemical composition is diverse, and rarely can a nidus be found. A differential diagnosis
of an enterolith requires the enterolith, a normal gallbladder, and a diverticulum
.
An enterolith typically forms within a diverticulum
. An enterolith formed in a Meckel's diverticulum
sometimes is known as a Meckel's enterolith. Improper use of magnesium oxide
as a long-term laxative
has been reported to cause enteroliths and/or medication bezoar
s.
Most enteroliths are not apparent and cause no complications. However, any complications that do occur are likely to be severe. Of these, bowel obstruction
is most common, followed by ileus
and perforation
. Bowel obstruction and ileus typically occur when a large enterolith is expelled from a diverticulum into the lumen. Perforation typically occurs within the diverticulum.
Most human enteroliths are radiolucent on plain X-rays. They sometimes can be visualized on CT scans without contrast; presence of contrast in the lumen may reveal the enterolith as a void. Most often, they are visualized using ultrasound.
Although recent surveys of enterolith composition are lacking, one early review notes struvite (as in equines), calcium phosphate
, and calcium carbonate
and reports choleic acid. Deoxycholic acid
and cholic acid
have also been reported.
of the involved segment.
Concretion
A concretion is a volume of sedimentary rock in which a mineral cement fills the porosity . Concretions are often ovoid or spherical in shape, although irregular shapes also occur. The word 'concretion' is derived from the Latin con meaning 'together' and crescere meaning 'to grow'...
or calculus
Calculus (medicine)
A calculus is a stone that forms in an organ or duct of the body. Formation of calculi is known as lithiasis...
formed anywhere in the gastrointestinal system. Enteroliths are uncommon and usually incidental findings but, once found, they require at a minimum watchful waiting
Watchful waiting
Watchful waiting is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed....
. If there is evidence of complications, they must be removed.
An enterolith may form around a nidus, a small foreign object such as a seed, pebble, or piece of twine, that serves as an irritant. In this respect, an enterolith forms by a process similar to the creation of a pearl.
An enterolith is not to be confused with a gastrolith
Gastrolith
A gastrolith, also called a stomach stone or gizzard stones, is a rock held inside a gastrointestinal tract. Gastroliths are retained in the muscular gizzard and used to grind food in animals lacking suitable grinding teeth. The grain size depends upon the size of the animal and the gastrolith's...
, which helps digestion.
In equines
Equine enteroliths are found by walking pastures or turning over manure compost piles to find small enteroliths, during necroscopy, and increasingly during surgery for colicColic
Colic is a form of pain which starts and stops abruptly. Types include:*Baby colic, a condition, usually in infants, characterized by incessant crying*Renal colic, a pain in the flank, characteristic of kidney stones...
. Therefore, the incidence of asymptomatic enteroliths is unknown.
Equine enteroliths typically are smoothly spherical or tetrahedral, consist mostly of the mineral struvite
Struvite
Struvite is a phosphate mineral with formula: NH4MgPO4·6H2O. Struvite crystallizes in the orthorhombic system as white to yellowish or brownish-white pyramidal crystals or in platey mica-like forms. It is a soft mineral with Mohs hardness of 1.5 to 2 and has a low specific gravity of 1.7...
(ammonium
Ammonium
The ammonium cation is a positively charged polyatomic cation with the chemical formula NH. It is formed by the protonation of ammonia...
magnesium
Magnesium
Magnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
phosphate
Phosphate
A phosphate, an inorganic chemical, is a salt of phosphoric acid. In organic chemistry, a phosphate, or organophosphate, is an ester of phosphoric acid. Organic phosphates are important in biochemistry and biogeochemistry or ecology. Inorganic phosphates are mined to obtain phosphorus for use in...
), and have concentric rings of mineral precipitated around a nidus.
Enteroliths in horse
Horse
The horse is one of two extant subspecies of Equus ferus, or the wild horse. It is a single-hooved mammal belonging to the taxonomic family Equidae. The horse has evolved over the past 45 to 55 million years from a small multi-toed creature into the large, single-toed animal of today...
s were reported widely in the 19th century, infrequently in the early 20th century, and now increasingly. They have also been reported in zebra
Zebra
Zebras are several species of African equids united by their distinctive black and white stripes. Their stripes come in different patterns unique to each individual. They are generally social animals that live in small harems to large herds...
s: five in a zoo
Zoo
A zoological garden, zoological park, menagerie, or zoo is a facility in which animals are confined within enclosures, displayed to the public, and in which they may also be bred....
in California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
and one in a zoo in Wisconsin
Wisconsin
Wisconsin is a U.S. state located in the north-central United States and is part of the Midwest. It is bordered by Minnesota to the west, Iowa to the southwest, Illinois to the south, Lake Michigan to the east, Michigan to the northeast, and Lake Superior to the north. Wisconsin's capital is...
. Struvite enteroliths are associated with elevated pH
PH
In chemistry, pH is a measure of the acidity or basicity of an aqueous solution. Pure water is said to be neutral, with a pH close to 7.0 at . Solutions with a pH less than 7 are said to be acidic and solutions with a pH greater than 7 are basic or alkaline...
and mineral concentrations in the lumen. In California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
, struvite enteroliths are associated also with a high proportion of alfalfa
Alfalfa
Alfalfa is a flowering plant in the pea family Fabaceae cultivated as an important forage crop in the US, Canada, Argentina, France, Australia, the Middle East, South Africa, and many other countries. It is known as lucerne in the UK, France, Australia, South Africa and New Zealand, and known as...
in the feed and less access to grass pasture. This association has been attributed to the cultivation of alfalfa on serpentine soil
Serpentine soil
A serpentine soil is derived from ultramafic rocks, in particular serpentinite, a rock formed by the hydration and metamorphic transformation of ultramafic rock from the Earth's mantle....
s, resulting in high concentrations of magnesium
Magnesium
Magnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
in the alfalfa.
In humans
In humanHuman
Humans are the only living species in the Homo genus...
s, enteroliths are rare and may be difficult to distinguish from gall stones. Their chemical composition is diverse, and rarely can a nidus be found. A differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
of an enterolith requires the enterolith, a normal gallbladder, and a diverticulum
Diverticulum
A diverticulum is medical or biological term for an outpouching of a hollow structure in the body. Depending upon which layers of the structure are involved, they are described as being either true or false....
.
An enterolith typically forms within a diverticulum
Diverticulum
A diverticulum is medical or biological term for an outpouching of a hollow structure in the body. Depending upon which layers of the structure are involved, they are described as being either true or false....
. An enterolith formed in a Meckel's diverticulum
Meckel's diverticulum
A Meckel's diverticulum, a true congenital diverticulum, is a small bulge in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct , and is the most frequent malformation of the gastrointestinal tract...
sometimes is known as a Meckel's enterolith. Improper use of magnesium oxide
Magnesium oxide
Magnesium oxide , or magnesia, is a white hygroscopic solid mineral that occurs naturally as periclase and is a source of magnesium . It has an empirical formula of and consists of a lattice of Mg2+ ions and O2– ions held together by ionic bonds...
as a long-term laxative
Laxative
Laxatives are foods, compounds, or drugs taken to induce bowel movements or to loosen the stool, most often taken to treat constipation. Certain stimulant, lubricant, and saline laxatives are used to evacuate the colon for rectal and/or bowel examinations, and may be supplemented by enemas under...
has been reported to cause enteroliths and/or medication bezoar
Bezoar
A bezoar is a mass found trapped in the gastrointestinal system , though it can occur in other locations. A pseudobezoar is an indigestible object introduced intentionally into the digestive system....
s.
Most enteroliths are not apparent and cause no complications. However, any complications that do occur are likely to be severe. Of these, bowel obstruction
Bowel obstruction
Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
is most common, followed by ileus
Ileus
Ileus is a disruption of the normal propulsive ability of the gastrointestinal tract.Ileus is commonly defined simply as bowel obstruction. However, authoritative sources define it as decreased motor activity of the GI tract due to non-mechanical causes...
and perforation
Gastrointestinal perforation
Gastrointestinal perforation is a complete penetration of the wall of the stomach, small intestine or large bowel, resulting in intestinal contents flowing into the abdominal cavity. Perforation of the intestines results in the potential for bacterial contamination of the abdominal cavity...
. Bowel obstruction and ileus typically occur when a large enterolith is expelled from a diverticulum into the lumen. Perforation typically occurs within the diverticulum.
Most human enteroliths are radiolucent on plain X-rays. They sometimes can be visualized on CT scans without contrast; presence of contrast in the lumen may reveal the enterolith as a void. Most often, they are visualized using ultrasound.
Although recent surveys of enterolith composition are lacking, one early review notes struvite (as in equines), calcium phosphate
Calcium phosphate
Calcium phosphate is the name given to a family of minerals containing calcium ions together with orthophosphates , metaphosphates or pyrophosphates and occasionally hydrogen or hydroxide ions ....
, and calcium carbonate
Calcium carbonate
Calcium carbonate is a chemical compound with the formula CaCO3. It is a common substance found in rocks in all parts of the world, and is the main component of shells of marine organisms, snails, coal balls, pearls, and eggshells. Calcium carbonate is the active ingredient in agricultural lime,...
and reports choleic acid. Deoxycholic acid
Deoxycholic acid
Deoxycholic acid, also known as deoxycholate, cholanoic acid, and 3α,12α-dihydroxy-5β-cholanate, is a bile acid. Deoxycholic acid is one of the secondary bile acids, which are metabolic byproducts of intestinal bacteria. The two primary bile acids secreted by the liver are cholic acid and...
and cholic acid
Cholic acid
Cholic acid is a bile acid, a white crystalline substance insoluble in water , with a melting point of 200-201 °C. Salts of cholic acid are called cholates. Cholic acid, along with chenodeoxycholic acid, is one of two major bile acids produced by the liver where it is synthesized from cholesterol...
have also been reported.
Treatment
In simple cases of obstruction, where there are no complications, a variety of non-surgical and surgical techniques are used to remove the enterolith. These include crushing the enterolith and milking it back to the stomach or forward to the colon, surgical removal via an uninvolved segment of the gastrointestinal tract, and resectionSegmental resection
Segmental resection is a surgical procedure to remove part of an organ or gland. It may also be used to remove a tumor and normal tissue around it. In lung cancer surgery, segmental resection refers to removing a section of a lobe of the lung.- External links :* entry in the public domain NCI...
of the involved segment.