EP894 - Rare Case of Fecaloma in a Patient with Crohn’s Disease Requiring Surgical Removal

Purpose/Background: A fecaloma is a collection of hardened stool, typically occurring in the sigmoid colon or rectum. Large fecalomas can result in large bowel obstruction with progression to ischemia and bowel perforation. Fecalomas typically occur in patients with chronic constipation especially the elderly and children, or those with chronic inflammatory conditions. Medical management with laxative agents is the first line of treatment, but severe cases may require manual or endoscopic disimpaction. Surgical removal is reserved for complications such as perforation, or for cases refractory to less invasive approaches. In this report, we highlight a rare case of fecaloma requiring laparotomy for extraction after undergoing multiple unsuccessful transanal and endoscopic attempts.

Methods/Interventions: A 75-year-old male with a history of anoperineal Crohn's disease managed with infliximab who presented with a known rectal fecaloma which had been present for at least 10 years. He reported a history of approximately 20 watery bowel movements every day for at least that duration. He had previously been noted to have anal stenosis which had been managed with dilation. Multiple unsuccessful attempts had been made to remove the fecaloma, including endoscopic removal utilizing a snare to attempt to fracture the fecaloma and transanal removal under anesthesia with holmium laser lithotripsy. On endoscopic evaluation, he was noted to have an 8 cm calcified fecaloma and nodular mucosa in his distal rectum suspected to be secondary to mechanical trauma from the fecaloma. As the fecaloma was hypothesized to be causing the patient's erratic bowel habits via a ball-valve mechanism, another endoscopic attempt was made with chemical dissolution which was again unsuccessful.

Results/Outcomes: The patient was offered transabdominal removal and he elected to proceed. He underwent laparotomy with creation of a 4 cm colotomy to successfully remove the fecaloma. The colotomy was then closed primarily. Postoperatively, he recovered without any complications and was discharged on postoperative day 1 tolerating diet, pain well controlled, and having return of bowel function.

Conclusion/Discussion: This report describes a rare case of a fecaloma requiring transabdominal removal. Given the patient's history of anoperineal Crohn's disease and known anal stricture, it is likely that the fecaloma developed secondary to obstruction from the stricture. Presumably, the fecaloma repeatedly impacted in his distal rectum functioning as a ball-valve, which then resulted in mucosal trauma and irregular bowel habits. The fecaloma was safely removed via laparotomy and colotomy without complication

Extraction of Fecaloma
Fecaloma extraction from colostomy incision
Fecaloma Specimen
Gross Image of Fecaloma with Measurement