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Introduction In penetrating Crohn’s disease, fistulous involvement of the stomach or duodenum is uncommon, and concurrent gastrocolic and duodenocolic fistulae are exceptionally rare. These fistulae typically present with severe or refractory symptoms, prompting reactive surgical management.Methods We report a case of a patient with longstanding Crohn’s disease in whom concurrent gastrocolic and duodenocolic fistulae were incidentally detected during work up of acute cholecystitis. Clinical history, cross-sectional imaging, endoscopic findings, histopathology, operative management and postoperative outcomes were reviewed.Results A 61-year-old man with a 17-year history of colonic Crohn’s disease, in clinical remission on azathioprine monotherapy, presented with an acute history of right upper quadrant pain, vomiting, and fever. There had been no gastroenterologist input nor endoscopic assessment of disease activity over 10 years. He reported minimal chronic symptoms. Biochemistry and radiology supported a diagnosis of acute calculous cholecystitis. Cross sectional imaging incidentally demonstrated complex fistulous connections between the transverse colon, stomach, and first part of the duodenum ( figure 1). Endoscopy showed a short transverse colon stenosis and suspected fistula openings, with histopathology demonstrating predominantly quiescent luminal disease.Following multidisciplinary discussion, the fistulae were addressed opportunistically at the time of planned elective cholecystectomy, with extended right hemicolectomy and surgical excision and repair of the fistulae. Histopathology of the resected bowel macroscopically showed mucosal cobblestone morphology and a prominent stricture at the terminal end of the transverse colon, with deeper microscopic analysis revealing transmural inflammation, ulceration, architectural distortion and severe active chronic inflammatory cell infiltrates. The postoperative course was uncomplicated.Conclusions This case demonstrates that complex internal fistulisation in Crohn’s disease may remain clinically silent for prolonged periods, even with gastric and duodenal involvement, and may only be detected incidentally. Additionally, this case reinforces the clinical disparity of penetrating complications attributed to cumulative transmural damage despite quiescent mucosal disease.Most notably, this case is unique in the opportunistic surgical management of incidentally detected fistulae, prior to the development of fistula-related complications and morbidity. In contrast, previously reported cases have typically involved reactive surgical management following severe or refractory symptoms. Our approach allows for definitive treatment in stable, nutritionally preserved patients, and has important implications for favourable patient outcomes and the ongoing management of longstanding Crohn’s disease.Abstract P252 Figure 1Transverse Computed Tomography section showing gastro- and duodenocolic fistulae