Retrograde double-balloon endoscopy-assisted electrohydraulic lithotripsy: Effective treatment of a true-enterolith associated with Crohn’s disease

A 42-year-old man with a history of Crohn’s disease was referred for treatment of an enterolith. The patient had no symptoms such as abdominal pain or nausea. Abdominal X-ray and computed tomography (CT) scan showed a 2.8-cm enterolith in the ileum ([Fig. 1], [Fig. 2]). Intestinal stenosis was found 10 cm proximal from the Bauhin’s valve with an enterolith on the proximal side of the stenosis ([Fig. 3]). The stenosis was dilated with a balloon catheter. Because the enterolith often moved into the oral side of the intestinal tract, retrograde double-balloon endoscopy (DBE) was performed using an EI-580BT endoscope (Fujifilm, Tokyo, Japan). We tried to crush the stone using biopsy forceps, polypectomy snares and crusher catheters, but the stone was too hard and none were effective. Surgery or electrohydraulic lithotripsy (EHL) were suggested as treatment options, and the patient chose EHL. We surrounded the stone with water, and EHL was performed ([Video 1]). The stone gradually cracked and fragmented into pieces ([Fig. 4]). We removed it using a disposable loop net ([Fig. 5]). Calculus analysis revealed that the main component of the enterolith was calcium oxalate, which indicates that the stone was a true-enterolith.

Fig. 1 X-ray revealed a 2.8-cm stone in the lower abdomen.

Fig. 2 CT scan showed a 2.8-cm high absorption enterolith in the ileum.

Fig. 3 An enterolith was found on the proximal side of the stenosis.

Video herunterladen

Treatment of an enterolith using electrohydraulic lithotripsy by double-balloon endoscopy. Video text: Retrograde double-balloon endoscopy was performed. Intestinal stenosis was found 10 cm proximal from the Bauhin’s valve. The stenosis was dilated up to 15 mm with a balloon catheter. An enterolith was found on the proximal side of the stenosis. We surrounded the stone with water. Electrohydraulic lithotripsy (EHL) was performed. The stone gradually cracked, and finally split into two. Additional EHL was performed to further split the stone. The stone was removed using a disposable loop net.Video 1

Fig. 4 The stone gradually cracked, and split into two.

Fig. 5 The stones removed from the ileum.

Performance of EHL for enterolith [1] [2], and treatment of enteroliths by balloon-assisted enteroscopy using other endoscopic devices [3] have been described. However, performance of EHL by double-balloon endoscopy for a true-enterolith in the ileum is extremely rare [4], and surgery is often selected for treatment [5]. Use of EHL was successful in avoiding surgery for a true-enterolith that could not be crushed with other endoscopic devices. Application of EHL could be recommended as a less invasive option to treat enteroliths.

Conclusions

In summary, we report the treatment of a true-enterolith in a patient with Crohn’s disease using electrohydraulic lithotripsy by retrograde DBE endoscopy, thereby avoiding surgery.

• References

• 1 Jihye L, Hoonsub S, Sung WK. et al. Endoscopic electrohydraulic lithotripsy of an enterolith causing afferent loop syndrome after Whipple’s operation. Endoscopy 2020; 52: E176-E177
• 2 Hwa JK, Jong HM, Hyun JC. et al. Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy. Dig Endosc 2010; 22: 220-222
• 3 Ishioka M, Jin M, Matsuhashi T. et al. True primary enterolith treated by balloon-assisted enteroscopy. Intern Med 2015; 54: 2439-2442
• 4 Grettve S. A contribution to the knowledge of primary treconcrements in the small bowel. Acta Chir Scand 1947; 95: 387-410
• 5 Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007; 31: 1292-1297