S55 Pouch Enteroliths Resulting in Stercoral Hemorrhage: An Extremely Rare Complication of a Chronic Rectal Cuff Stricture in an Ileoanal Pouch

Case: Background: Enterolithiasis in the bowel is a rare condition. Less than 30 cases of enterolithiasis in Crohn's disease patients have been reported. Within the medical literature, a single case of pouch enteroliths has been reported. Herein, we described an extremely rare case of a patient with pouch stricture and enteroliths. Case: A 65-year-old male with morbid obesity, coronary artery disease, and a history of pulmonary embolism presented to the outpatient office endorsing 15-18 non-bloody liquid bowel movements daily, abdominal pain and cramping for 2 months. He denied nausea, vomiting, weight loss. He has a history of presumed ulcerative colitis s/p IPAA in 1988 and his diagnosis transitioned to Crohn’s disease for known pouch-anal anastomotic stricture requiring serial dilations for the past twenty years. He was on no biologics. His last pouchoscopy was performed 12 months prior and revealed stricture at the anus and stricture at the pouch inlet without pouchitis. Of note, several months prior to being seen he had a lower GI hemorrhage from the cuff requiring several transfusions. During his office visit, findings were notable for severe stenosis of the anal canal on digital rectal exam. CT enterography demonstrated a stricture at the pouch inlet with active inflammation, mild mucosal hyperenhancement of the lower pouch extending into the anus concerning for pouchitis, and perianal soft tissue stranding without discrete fistula tract identified. He was taken to the operating room for a pouchoscopy which identified a long 5 cm rectal cuff which was strictured and dilated. Upon dilation, a large amount of liquid stool was lavaged endoscopically to decompress the pouch; after further lavage, half a dozen large enteroliths with sharp edges were removed with a Roth net, snare, and ring forceps. Further pouch intubation was performed to the inlet stricture, which was endoscopically passable. Strictures were both biopsied and revealed chronic active enteritis with ulceration and pyloric gland metaplasia, negative for granulomas or dysplasia. In the follow-up, the patient was started a 3-month taper of budesonide with plan to restart biologics in the future if a response was seen on endoscopy. Pouchoscopy was repeated one week after budesonide was started; the procedure revealed worsening inflammation of the afferent limb. No enteroliths were found. Patient is planned for further surgical discussion and staged intervention with diverting ileostomy, leading to possible pouch excision in the future. Discussion: Strictures will form in up to 40% in patients with Crohn’s disease and may lead to obstructive symptoms, but also fecal stasis - the most important factor in the development of enteroliths. Studies have shown that enterolithiasis in Crohn’s disease occurs only in patients with a long history of mainly untreated symptoms of between 7 and 40 years. Thus, it is critical that rectal cuff strictures be managed surgical to avoid complications by experts, for patients to keep up with endoscopic surveillance, as well as referral to a colorectal surgeon for further management of the strictures to avoid the development of this uncommon complication.