A rock in a hard place. Removal of a large fecalith assisted by mechanical lithotripsy. These are our disclosures. Fecaliths are collections of retained stool which can harden over time and may require endoscopic removal when they become symptomatic. They also serve as a nidus of infection or ischemia. Large fecaliths can be difficult to remove due to a variety of patient-specific factors. This case highlights the novel use of a mechanical lithotriptor to fragment an existing large fecalith, allowing removal across a narrow ilioanal anastomosis. This case presents a 69-year-old man with a past medical history of Crohn's-like pouchitis on infliximab and azathioprine who presented to the Digestive Health Clinic with increasing gastrointestinal symptoms from baseline. He underwent pouchoscopy and was found to have mild inflammation in the pre-pouch ileum in addition to a large 2.5-centimeter fecalith within the tip of the ilioanal anastomosis. Removal of the fecalith was attempted with an endoscopic net. The fecalith was successfully captured in the endoscopic net but was unable to cross the anal verge due to impaction at the ilioanal anastomosis. Biopsy forceps and snare electrocautery were used to attempt fragmentation of the fecalith and both were unsuccessful. The patient underwent repeat pouchoscopy approximately 90 days later with the primary intent of fecalith removal aided by lithotripsy. The fecalith was identified and repositioned into the mid-pouch with an endoscopic net. An endoscopic mechanical lithotriptor was used to fragment the fecalith. The endoscopic net was reintroduced and used for stone fragment removal through the ilioanal anastomosis with moderate resistance. There were no procedural complications. Here you can see the existing stenosed ilioanal anastomosis. The fecalith was repositioned into the mid-pouch. The mechanical lithotriptor was introduced and positioned over the fecalith for fragmentation. Fragmentation by mechanical lithotriptor was successful. The endoscopic net was reintroduced for removal of the fragments. Typical fecalith removal techniques including cold forceps or use of an endoscopic net may be suitable for small fecaliths. Large fecaliths can be difficult to remove due to patient anatomy, especially in the setting of surgical anastomosis from prior abdominal surgery. The endoscopic net was reintroduced for removal of the fragments. or strictured gastrointestinal lumens from inflammatory bowel disease. Standard techniques to remove fecaliths endoscopically include use of biopsy forceps, snares, endoscopic nets, suction, and washing and diluting with warm water. These techniques may be useful in patients with native colorectal anatomy or small fecaliths. In patients with large fecaliths, surgical anastomosis, or strictured lumens, consideration of fragmentation of the fecalith should be made. Lithotripsy can be a useful technique to aid in fragmentation and removal of large fecaliths endoscopically when standard techniques fail.

Crohn's-like pouchitis

fecalith

ilioanal anastomosis

endoscopic net

mechanical lithotriptor