1477 A Rare Case of Successful Endoscopic Decompression of Ileal-Pouch Volvulus

Abstract

INTRODUCTION: Ileal-pouch anal anastomosis is a common surgery to restore bowel continence after total proctocolectomy. Obstruction is the most common late complication and occurs in up to 25% of cases. However, Ileal-pouch volvulus is an exceedingly rare complication of this procedure with only 16 published cases. All but one were treated with emergent surgical intervention. We present the second case of successful endoscopic decompression and the first reported in a patient with familial adenomatous polyposis (FAP). CASE DESCRIPTION/METHODS: A 33-year-old female with FAP status-post total proctocolectomy with ileoanal anastomosis and J-pouch formation complicated by history of ventral hernia repair and pouchitis presented with one week of severe left sided abdominal pain and emesis. On the day of presentation she noted new onset of abdominal distension causing her to present to the emergency room. The patients work up was notable for urosepsis, leukocytosis, AKI, hyperkalemia and a metabolic acidosis. A CT showed dilated small bowel loops swirled around a transition point in the left lower quadrant. A barium enema confirmed the diagnosis with barium that did not pass the distal rectum but was not therapeutic. Flexible sigmoidoscopy was then performed and showed twisted bowel with stenosis at 20 cm proximal to the anus. The endoscope was gently advanced with minimal CO2 insufflation and the stenosis re-opened, revealing dark gray, edematous mucosa with black spots. Proximally and distally, the mucosa appeared healthy. A colonic decompression tube was inserted to prevent future volvulus. The patient underwent exploratory laparotomy seven days later. No volvulus or bowel ischemia was found at that time and the pouch appeared viable. Extensive lysis of adhesions in the right upper quadrant and reduction of an internal hernia were performed. A small segment of small bowel was resected due to serosal injury. The patient then completed a course of antibiotics and was discharged home. DISCUSSION: This is a unique case of an extremely rare complication of an Ileal-pouch anal anastomosis. Additional abdominal surgeries, pouchitis and sepsis have been described as risk factors for pouch complications, all of which occurred in our patient and may have contributed to this rare presentation. Endoscopic decompression, if done expeditiously, may prevent loss of the pouch and need for surgical repair. This demonstrates the need for high clinical suspicion and awareness of this rare complication.