1493 Large Fecalith Obstructing the Cecum in a Patient With Rectal Bleeding and Iron Deficiency Anemia

Abstract

INTRODUCTION: Fecal impaction as a result of fecalith formation can lead to rare but serious complications, such hemorrhage, perforation, intussusception and bowel obstruction. Fecaliths are stones made of feces and are a common finding in clinical practice. A fecaloma is a giant fecalith. Patients typically present with overflow diarrhea, constipation, and abdominal pain. Fecalomas are usually located in the sigmoid colon or rectum, but are rarely seen in the cecum. We present a case of a patient with a fecaloma obstructing the cecum, causing ischemic stricture. CASE DESCRIPTION/METHODS: The patient is a 79-year-old man without a significant past medical history who was referred to gastroenterology clinic for iron deficiency anemia, bloating, intermittent rectal bleeding, and chronic constipation. Home medications include ferrous sulfate. Patient's last colonoscopy was 7 years ago and was significant for internal hemorrhoids. No significant family history. Due to anemia and rectal bleeding he was scheduled for colonoscopy. Colonoscopy revealed the presence of a large, obstructing fecalith in the cecum, with evidence of luminal narrowing. After several attempts, it was removed endoscopically with a large 27 mm hexagonal snare. It was subsequently split into smaller pieces in the transverse colon due to concerns for obstruction. Iron supplementation was stopped. Follow-up colonoscopy revealed a smooth circumferential luminal narrowing of the right side of the colon likely due to ischemic changes from the pressure effect created by the fecalith. The patient was seen in clinic 2 weeks afterwards with significant improvement of his symptoms. DISCUSSION: Although fecaliths are a frequent finding in clinical practice, luminal obstruction and ischemic changes resulting in stricture formation are rare. The need for surgery in our patient was avoided due to successful removal of the fecalith. At this point we believe that iron supplementation caused the fecalith formation, resulting in obstruction and ischemic stricture. Our case illustrates an alternative non-invasive way to manage cecal fecaliths in symptomatic patients thus preventing the need for surgery.