VM14 - Pouchoscopy with Transanal Stone Extraction of Pouch Enteroliths

Purpose/Background: Enterolithiasis is a rare medical condition with a prevalence of 0.3 - 10% in certain patient populations, and is associated with intestinal stasis, which may occur in conditions such as enteric anastomoses, diverticuli, and blind pouches or roux limbs. A handful of prior reports have described the associated symptoms including abdominal pain, ileus, bleeding, perforation, and bowel obstruction. Given the affinity for progressive stricturing with luminal narrowing in patients with inflammatory bowel disease (IBD), several case reports have described the development of enterolithiasis after an average of 15-years of IBD-related symptoms. Herein, we present a case of life-threatening rectal hemorrhage in a patient with Crohn’s-like disease of the ileoanal pouch. This was subsequently found to be due to enterolithiasis within the ileal pouch proximal to the chronic severe rectal cuff stricture. Pouchoscopy with transanal stone extraction of multiple pouch enteroliths was performed.

Methods/Interventions: A 65-year-old male with a history of ulcerative colitis with an ileoanal pouch presented for a 2nd opinion after receiving multiple blood transfusions for rectal bleeding of unclear etiology, despite multiple pouchoscopic examinations for chronic pouch anal anastomotic stricture at the referring center. The patient also noted foul- smelling stool with increased frequency. At the time of our examination under anesthesia, a digital rectal examination revealed a long rectal stricture requiring dilation. Pouchoscopy demonstrated approximately a half-dozen 1x1 to 2x4 cm enteroliths within the body of the pouch; the stones were noted to have sharp edges. Multiple endoscopic methods, including Roth net, snare, and transanal ringed forceps, were used to clear the enteroliths en bloc and piecemeal.

Results/Outcomes: At the 1-month and 1-year follow-ups, he showed significant symptom improvement with decreased stool odor, resolution of bleeding, and improved bowel frequency. Biopsies of the pouch revealed chronic active enteritis and proctitis, with ulceration and pyloric gland metaplasia. He currently remains on budesonide and risankizumab and has since undergone four repeat pouchoscopies with persistent stricture requiring dilation but without enterolith recurrence.

Conclusion/Discussion: Our case presents an unusual presentation of enteroliths that developed proximal to a severe rectal stricture. Although rare, enteroliths in IBD with stricturing disease should be considered in the differential diagnosis of recurrent pouchitis, bleeding, and abnormal pouch function. Pouchoscopy with transanal stone extraction is highly feasible.