Pharmacobezoar: A Rare Complication After Ileal Pouch–Anal Anastomosis for Ulcerative Colitis

34-year-old woman underwent a proctocolectomy with ileal J-pouch–anal anastomosis for refractory ulcerative colitis in 2002. She did experience frequent episodes of pouchitis treated with antibiotics and was given medications for abdominal discomfort. HyoMax-SR 0.375 mg (sustained-release hyoscyamine; Aristos Pharmaceuticals, Shampur-Kadamtali, Dhaka) was ordered to treat intestinal spasms. The patient ingested 1 tablet twice a day for 1 year before consulting us for lower abdominal pain, frequent liquid stools, and incontinence. She denied the use of any other medications during that time period. Her physical exam was unremarkable. The patient declined a digital rectal examination because of discomfort. Computed tomography showed an abnormally distended ileal pouch containing numerous pill fragments (Figure A). Under general anesthesia, no significant anastomotic stricture was detected, but undigested capsules were palpated in the pouch. A pouchoscopy confirmed the presence of a large amount of retained pills (Figure B). Mild inflammation of the mucosa was apparent without any ulcers. The pills were extracted transanally by using a ring forceps. A Roth foreign body retrieval net (US Endoscopy, Mentor, OH) was used to remove the pills located more proximally in the pouch. A total of 575 pills were extracted (Figure C). Biopsies from the ileal pouch showed chronic nonspecific pouchitis. During the early postoperative period, her abdominal pain and incontinence had resolved. The stool consistency improved, and the patient could empty her pouch spontaneously. She was advised to discontinue the use of hyoscyamine. Hyoscyamine is an anticholinergic/antispasmodic that inhibits gastrointestinal propulsive motility and decreases gastric acid secretion. The outer shell of the sustained-release tablet is made of a cellulosebased matrix shell with small micropores. This allows for a slow, sustained release of the active drug. The shell might not be completely absorbed and can be excreted in the stool. The mechanism leading to the selective impaction of the pills in the ileal pouch remains unclear. A functional obstruction combined with the effects of this medication on intestinal motility might explain the findings.