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A large gallstone erodes its way into the intestine, usually the duodenum, from the gall bladder generating a bilio-enteric fistula. The gall stone may pass through the intestine, or if it is large is may get held up. Where it gets held up depends on the size of the gallstone and intestine. The narrowest part of the small intestine is in the terminal ileum about 2 feet proximal to the ileo-caecal valve. The gallstone will intermittently block and unblock the intestine with liquid chyme often passing around it until it gets held fast. Thus the clinical picture may that of an ileus rather than severe obstruction. If a plain abdominal film is closely inspected gas may be visible in the biliary tree (pneumo-bilia). Some of these stones are radio-opaque, they may be visible on CT scanning even if they are not visible on plain abdominal films. If the diagnosis is made pre-operatively only a small incision is required. A longitudinal enterotomy is made in the proximal intestine and the stone milked back and out the hole, then the enterotomy is closed. The bilio-enteric fistula is left alone.

A concretion of undigested matter may block the lumen of the bowel. For instance a large amount of hair may accumulate in the stomach (tricho-beezoar) in people who eat their hair (tricho-tillo-mania). People who eat a lot of vegetable matter which is not chewed well enough may get a similar problem (phyto-beezoar). The beezoar will often be in the stomach as the job of the stomach is to liquefy the ingested material before passing it into the duodenum (antral mill). Some people develop an accumulation of undigested material in the small intestine if there is an anatomical abnormality such as jejeunal diverticulae.

Foreign body

Foreign bodies will occasionally cause a blockage in the intestine. The presence of a foreign body may be obvious from the history or it may be suspected due to unusual radiographic appearances. Most foreign bodies that will cause obstruction get caught in the esophagus. The narrow areas in the esophagus are at the start (crico-pharyngeus 15 cm from incisors), where the bronchus crosses (20 cm from the incisors), where there is an indentation from the left atrium (25 cm from the incisors) and at the end (gastro-esophageal junction 40 cm from the incisors). It may be possible to remove these endoscopically or to push them into the stomach where they may be more easily retrieved. There is some controversy about whether flexible or rigid endoscopy is best for removal of esophageal foreign bodies. Some foreign bodies are most easily removed with the flexible scope and some with the rigid scope. Both modalities are useful. Flexible endoscopy may be attempted under conscious sedation, and is more widely available and there is no doubt that more people are expert in the use of the flexible scope than in the use of the rigid scope. In addition, in patients without foreign bodies flexible endoscopy is associated with a lower rate of esophageal perforation than rigid endoscopy. The situation in patients with foreign bodies is more controversial, some surgeons advocate the primary use of rigid endoscopy in the case of foreign bodies, they maintain that it is safer. There is a significant risk of esophageal perforation due to impaction of a foreign body in the esophagus, particularly if removal is delayed of if the object is sharp. Patients should be warned about this risk prior to attempted removal.

Some psychiatric patients are repeat offenders and cause great misery to the physicians who treat them. Some surgeons refuse to treat such patients after numerous removals. This does not usually stop the patient though and the patient will be transferred around to different surgeons in different hospitals. It is not necessary to remove every foreign body, in any case.

Some prisoners, swallow metallic foreign bodies, for a day out of the prison. They may wrap a safety pin in cello-tape and then swallow that for instance. This however does not guarantee that they will not suffer a perforation.

next up previous index Surgical Topics
Next: Wall Up: Lumen, Wall, Outside or Previous: Lumen, Wall, Outside or   Index
Adrian P. Ireland