Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 8  |  Issue : 2  |  Page : 59-61
Small bowel perforation after extracorporeal shockwave lithotripsy for ureteric stone: A case report and review of the literature

Department of Surgery, Division of Urology, King Khalid University Hospital, P. Q Box 7805. Riyadh 11472, Saudi Arabia

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Date of Submission08-Jan-2002
Date of Acceptance10-Mar-2002

How to cite this article:
El-Faqih SR. Small bowel perforation after extracorporeal shockwave lithotripsy for ureteric stone: A case report and review of the literature. Saudi J Gastroenterol 2002;8:59-61

How to cite this URL:
El-Faqih SR. Small bowel perforation after extracorporeal shockwave lithotripsy for ureteric stone: A case report and review of the literature. Saudi J Gastroenterol [serial online] 2002 [cited 2022 Dec 3];8:59-61. Available from:

Since its introduction in Germany in 1980. extracorporeal shockwave lithotripsy (ESWL) has proved to be safe, effective and is currently regarded as the preferred method of treatment of over 90% of upper urinary tract stones [1],[2] . Extracorporeal shockwave lithotripsy, nevertheless, is not devoid of complications. Although the majority are trivial and transient, serious complications do occur but are extremely rare and only very few have been reported in the literature [3] .

In this paper we report a case of small intestinal perforation following ESWL treatment of right mid­ureteric stone in prone position and review the literature for serious gastrointestinal and hepato­pancreatic complications of ESWL for upper urinary tract stones.

   Case Report Top

A 38-year old, average built male patient, 172cm height and 75kg weight, presented with a 10mm x 6mm stone in the iliac part of the right ureter. He underwent ESWL in prone position after having the usual bowel preparation of castor oil and fleet enema given the night before. He had a total of 4000 shocks at energy level of 6.5 (range 1-9) delivered by a Siemens lithostar plus lithotripter utilizing system c shockwave head. His stone was well fragmented and he was supposed to go home in the afternoon of the same day but was kept under observation because he felt unwell, with central abdominal pain and low-grade fever of 38°C. The abdomen was tender and bowel sounds were absent. His condition continued to deteriorate and by the evening of the same day, he developed full-blown clinical picture of peritonitis. Plain erects abdominal and chest x-ray showed air under the right diaphragm. A clinical diagnosis of perforated viscus was made and laparotomy was performed. After cleaning the peritoneal cavity from the spilled small intestinal contents, a single clean-cut perforation was found in a loop of the proximal part of the ileum. the area around the hole and the rest of small intestine looked normal. The caecum and the part of the ascending colon overlying the stone-bearing part of the ureter looked normal with no bruises and there was no retroperitoneal or mesenteric hematomas. The area of perforation was resected and end to end anastomosis was done. The patient had uneventful post-operative recovery. Histology of the resected part of the small intestine did not reveal any underlying pathology.

The sequence of events, the intra-operative findings, the histopathology result and the absence of predisposing gastrointestinal disease together with a negative history of analgesic or steroid intake, all support that ESWL is the most likely cause of the small intestinal perforation in this patient.

   Discussion Top

The results and safety record of ESWL. which was originally designed to treat renal stones, were so good that its indications have been expanded to include stones in the rest of the urinary tract as well as stones in organs outside the urinary tract [3] . It has been used to treat gall bladder stones, extrahepatic and intrahepatic bile duct stones and pancreatic duct stones [8] . Nevertheless various ESWL complications have been described [4],[5],[6],[7],[9] These complications are classified as those associated with poor fragment clearance and those related to shockwave energy injury of the target organ or the adjacent organs. The proximity of the gastrointestinal tract and gastrointestinal tract related organs to the kidney and ureter makes them more prone to shockwave energy side effects. Serious intestinal, liver, and pancreatic injuries, although extremely rare, have been reported [10],[11],[12],[13],[14],[15],[16],[17],[22],[23],[24],[25],[26] .

While it has been clinically and experimentally demonstrated that gastro-intestinal mucosal erosions, ecchymosis and petecheal hemorrhages occur in subclinical forms more frequently than expected, major complications are extremely rare [10] . In addition to our, hereby presented case, only five other cases of small intestinal perforation and two cases of large bowel perforation have been reported in the literature so far [11],[12],[13],[14],[15],[16],[17] . Our patient and six of the patients reported were treated for ureteric stones in prone position and the seventh one was also treated in prone position but for renal pelvic stone.

The good fragmentation of the ureteric stone in our patient indicates that it was well focused upon and the ileum must have been away from the point of maximum pressure. The logic explanation of the intestinal perforation, therefore, is that while the patient in prone position, a trapped gas-filled loop of intestine gets exposed to the path of the high energy focused shockwaves; and the high pressure released because of the significant difference in acoustic impedance between the gas and the intestinal tissue is the most likely cause of intestinal damage. The occurrence of such injuries in prone position should not deter or put-off urologists from using this position when indicated. In our experience as well as worldwide experience prone position has been proved to be safe, effective and, since its introduction in 1988, it has allowed further expansion of ESWL indications [18],[19],[20] .

As the liver and pancreas are concerned, occasional transient elevations of liver enzymes and amylase were reported after ESWL for upper urinary tract stones, but they are usually clinically insignificant and it is unnecessary to monitor those enzymes on routine has is [3],[21] . Serious injuries on the other hand are extremely rare and only few have been reported in the literature. There are reports of one liver rupture, two liver subcapsular haematomas, one peri-pancreatic abscess and one acute pancreatitis [22],[23],[24],[25],[26]. The cavitation effect of shockwave energy on the parenchymal tissue has been postulated as a possible mechanism for such injuries [27] .

   Conclusion Top

Serious complications affecting the gastro­intestinal tract and its related organs are extremely rare after ESWL for renal and ureteric stones. The use of high energy and prone position may predispose to such complications. With the excellent safety record of ESWL and the extreme rarity of these complications, urologists should not be deterred from using prone position when indicated but caution should be taken particularly when treating patients in this position. The patients should have good bowel preparation to minimize the gas in the intestine, the gas-filled loops should be observed and the energy level modified accordingly during the treatment.

   References Top

1.Chaussy C, Schmiedt E, Jocham D et al. First clinical experience with extracorporeally induced destruction of kidney stones by shockwaves. J Urol 1982; 127: 417.  Back to cited text no. 1    
2.Streem SB. Contemporary clinical practice of shock wave lithotripsy: re-evaluation of contraindications. J Urol 1997, 157:1197-203.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Fuchs GJ, David RD, Fuchs AM. Complications of extracorporeal shockwave lithotripsy. Arch Esp Urol 1989, 42: 83-9.  Back to cited text no. 3  [PUBMED]  
4.Sackmann M, Delius M, Sauerbruch T et al. Shockwave lithotripsy of gallstones: The first 175 patients. N Engl J Med 1988; 318: 393.  Back to cited text no. 4    
5.Gilchrist AM, Ross B, Thomas WE. Extracorporeal shockwave lithotripsy for common bile duct stones. Br J Surg 1997, 84. 29-32.  Back to cited text no. 5    
6.El-Faqih SR, Al-Mofleh IA, Al-Rashed et al. Extracorporeal shockwave lithotripsy for the rescue of post endoscopic or surgically retained biliary duct stones. Does saline irrigation affect the outcome? Saudi J Gastroenterology, 1998; 43: 167-171.  Back to cited text no. 6    
7.Kim MH, Lee SK, Min Yl et al. Extracorporeal shockwave lithotripsy of primary intrahepatic stones. Korean J Intern Med 1992; 7: 25-30.  Back to cited text no. 7    
8.Ohara H, Hoshino M, Hayakawa T et al. Single application extracorporeal shockwave lithotripsy: The first choice for patients with pancreatic duct stones. Am .1 Gastroenterol 1996; 91: 1388-94.  Back to cited text no. 8    
9.Coptcoat MJ, Webb DR, Kellett MJ et al. The complications of extracorporeal shockwave lithotripsy: Management and prevention. Br J Urol 1986; 58: 578-80.  Back to cited text no. 9    
10.Al-Karawi MA, Mohamed AR, El-Etaibi KE, Abomelha MS, Seed RF. Extracorporeal shockwave lithotripsy induced erosions in upper gastrointestinal tract. Prospective study in 40 patients. Urology 1987,30: 224-7.  Back to cited text no. 10    
11.Klug R, Kurz F, Dunzinger M, Aufschnaiter MI. Small bowel perforation after extracorporeal shockwave lithotripsy of a ureteric stone. Dig Surg 2001; 18: 241-2.  Back to cited text no. 11    
12.Eric Olsson L, Kevin R, Anderson and Harris E, Foster JR. Small bowel perforation after extracorporeal shockwave lithotripsy. J Urol 2000; 164: 775.  Back to cited text no. 12    
13.Kurtz V, Muller Sorg M, Fedeermann G. Perforation of the small intestine after nephro-ureteral lithotripsy by ESWL: A rare complication. Chirug 1999; 70: 306-7  Back to cited text no. 13    
14.Holmberg G, Spinnell S, Sjodin JG. Perforation of the small bowel during SWL in prone position. J Endourol 1997;11:313-4.  Back to cited text no. 14    
15.Geh JL, Curley P, Mayfield MP, Price JJ. Small bowel perforation after extracorporeal shockwave lithotripsy. Br J Urol 1997; 79: 648-9.  Back to cited text no. 15  [PUBMED]  
16.Lipay M, Araujos, Perosa M, Gezini T, Hering F, Rodrigues P. Perforation of sigmoid colon after extracorporeal lithotripsy, J Urol 2000; 164: 442.  Back to cited text no. 16    
17.Castillon 1, Frieyro O, Gonzales-Enquita C, Vela-Navarette R. Colonic perforation after extracorporeal shockwave lithotripsy, BJU International 1999; 83: 720-1.  Back to cited text no. 17    
18.Husain I. El-Faqih SR. Renal stones in the tropics: Epidemiology, pathogenesis and current choices in non­surgical treatment. Asian J. Surg, 1995:18: 12-9.  Back to cited text no. 18    
19.Talic RF. Extracorporeal shockwave litrotripsy monotherapy in renal pelvic ectopia. Urology, 1996; 48: 857-61.  Back to cited text no. 19    
20.Miller K. Bachor R, Haufmann R. Electrohydraulic shockwave lithotripsy with ventral shockwave exposure: Technique, indications and initial clinical results. Urology A 1988; 27: 135-8.  Back to cited text no. 20    
21.Drach G, Dretler S, Fair W et al. Report of the United States cooperative study of extracorporeal shockwave lithotripsy. J Urol 1986; 135: 1127.  Back to cited text no. 21    
22.Bogdonovic J, Mirkovic M, Idjuski S, Popov M, Marusic G, Stojkov J. Liver injury related to extracorporeal shockwave lithotripsy in a quadriplegic patient. BJU International 1999;83:718-9.  Back to cited text no. 22    
23.Kobayashi K, Ishizuka E, Iwasaki A, Saito R. Subcapsular hematoma of the liver after extracorporeal shockwave lithotripsy. Nippon Hinyokika Gakkai Zasshi 1998: 89: 445-8.  Back to cited text no. 23    
24.Meyer JJ, Cass AS. Subcapsular hematoma of the liver after renal extracorporeal shockwave lithotripsy J Urol 1995. 154:516-7.  Back to cited text no. 24    
25.Hung SY, Chen HM, Jan YY, Chen MF. Common bile duct and pancreatic injury after extracorporeal shockwave lithotripsy for renal stone. Hepatogastroenterology 2000.. 47: 1162-3.  Back to cited text no. 25    
26.Abe H, Nisimura T, Osawa S, Miura T, Oka F. Acute pancreatitis caused by extracorporeal shockwave lithotripsy for bilateral renal pelvic calculi. Int J Urol 2000. 7: 65-8  Back to cited text no. 26    
27.Forer LE, Davros WJ, Goldberg J et al. Hepatic cavitation. A marker of transient hepatocellular injury during biliary lithotripsy. Dig Dis Sci 1992; 37: 1510-6.  Back to cited text no. 27    

Correspondence Address:
Salah Rashed El-Faqih
King Khalid University Hospital. P. 0. Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19861792

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