Enterolith obstruction of the small bowel.

Intestinal obstruction caused by an enterolith formed in a small bowel divertic-ulum is rare. In most cases the enterolith arises from a jejunal diverticulum in an elderly patient. When enterolith obstruction is diagnosed, the entire small bowel and gallbladder should be examined to determine the source. We present three cases and discuss the management options. CASE 1. A 37-year-old female presented with a four hour history of abdominal pain, nausea and vomiting. There was no past history of surgery. Abdominal examination revealed slight distension, generalised tenderness and diminished bowel sounds. Hernial orifices were normal. Radiography showed multiple dilated loops of small bowel. There was a polymorphonuclear leucocytosis of 15-0 x 109/1. At emergency laparotomy an inflamed Meckel's diverticulum was found, distal to which was an enterolith obstructing the terminal ileum. The remaining small bowel and gallbladder were normal. The diverticulum was excised and the enterolith milked back and removed via the enterotomy. Postoperative recovery was uneventful. CASE 2. A 70-year-old female presented with a four week history of crampy central abdominal pain, followed by nausea and vomiting. Bowel habit was regular. Appendicectomy and hysterectomy had been performed in 1939 and 1961 respectively. Abdominal examination revealed marked distension and increased bowel sounds. Hernial orifices were normal. Abdominal radiography showed dilated small bowel and a large laminated opacity in the pelvis (Fig 1). There was no air in the biliary tree. Initial conservative management failed, and at laparotomy a hard enterolith obstructing the terminal ileum was removed via an enterotomy. The source of the enterolith was found to be a large jejunal diverticulum which was invaginated into the lumen. Postoperative recovery was unremarkable. CASE3. A 90-year-old man presented with a ten day history of crampy abdominal pain, followed seven days later by distension and vomiting. Four years previously, sigmoid colectomy had been performed for diverticular disease, and