A ROCKY SITUATION. F. Francois 1 , J. Park 1 , C.T. Tenner 2 , S. Finkelstein 1 ; 1 New York University School of Medicine, Brooklyn, NY; 2 New York University School of Medicine, New York, NY (Tracking ID #74431) LEARNING OBJECTIVES: 1. Recognize the potential for bowel dysfunction in chronically ill patients 2. Consider the differential diagnosis of lower gastrointestinal bleeding in the elderly population 3. Review the management of stercoraceous masses. CASE INFORMATION: A 72-year-old HIV positive Hispanic male on highly active anti retroviral therapy (CD4 = 612 cells per cubic millimeter, viral load<50 copies per milliliter), was admitted for evaluation of hematochezia. The patient had a history of poorly controlled hypertension and had been hospitalized three weeks prior to this presentation with an acute change in mental status during which he was found to have a basal ganglia infarct. The family reported that the patient had been mainly bed bound since the stroke, and had intermittently complained of difficulty moving his bowels without any associated abdominal pain, nausea, or vomiting. On physical exam the patient was noted to have a right facial droop, right-sided hemiparesis, and normal active bowel sounds without abdominal distention, tenderness, or guarding. On rectal examination a freely mobile mass was palpated in the vault and bright red blood was seen on the glove. Laboratory evaluation was significant for a seven-point hematocrit drop from his baseline. On colonoscopy the patient was found to have 3 discontinuous areas of ulceration in the rectosigmoid region, with the largest measuring 6cm Â 2cm. The ulcers were associated with 3 large (4cm in diameter) hard fecal masses (fecalomas). The fecalomas were manually evacuated and the patient was started on a bowel regimen consisting of stool softeners and hydration. The patient's hematocrit remained stable with no further episodes of rectal bleeding and he was discharged to to the care of his family. IMPLICATIONS/DISCUSSION: Elderly patients may develop bowel dysfunction due to diabetes mellitus, hypothyroidism, renal failure, dementia, immobilization, cerebrovascular accidents, and medications. Once chronic constipation occurs the patients are at risk for fecal impaction and stercoral ulcers (a.k.a. Huntley syndrome). These ulcers result from pressure necrosis on the colonic mucosa by the rock-like fecal mass. Patients may present with rectal bleeding or colonic perforation with peritonitis. In the elderly population, the differential of hematochezia as a presenting sign in the setting of a change in bowel habits includes, malignancy, infectious colitis, and ischemic colitis. Initial management of a stercoral lesion involves manual evacuation of the stecoraceous mass followed by a bowel regimen with stool softeners along with adequate hydration. Patients with recurrent ulcer bleeding or perforation may require surgery as definitive therapy.