Chronic Antibody Refractory Pouchitis Associated With Abdominal Mesh in a 49-Year-Old Woman

Abstract

Restorative proctocolectomy with ilealoanal pouch-anal anastomosis (IPAA) is the standard surgical therapy for patients with medically refractory ulcerative colitis (UC), UC with dysplasia, or familial adenomatous polyposis. Complications of IPAA are common and include chronic antibiotic-refractory pouchitis (CARP), which may lead to pouch failure. The etiology and pathogenesis of CARP are illdefined. A 49-year-old woman with IPAA presented to our Pouch Center in September, 2013 with worsening pouchitis symptoms including increased bowel frequency and abdominal pain. She was diagnosed with UC in 1984. She underwent proctocolectomy 2-stage IPAA for steroid-dependent UC in 1995. In 1997 and 2007 she developed a small bowel obstruction (SBO) requiring exploratory laparotomy, adhesiolysis and ventral herniorrhaphy. During the 2007 surgery, partial pouch prolapse with volvulus was noted, prompting sacral pouchpexy involving the small bowel mesentery. Postoperative pouchoscopy showed no active inflammation. In 2009, she underwent elective herniorrhaphy with abdominal mesh placement for incisional hernia. She subsequently developed recurrent pouchitis and cuffitis and initially responded to oral rifaximin. She then developed CARP without response to rifaximin, ciprofloxacin, budesonide or suppositories of belladonna/opium, tincture of opium and hydrocortisone/lidocaine. Abdominal imaging in 2013 showed bulging of the mesh containing unobstructed small bowel loops. Pouchoscopy in May, 2014 revealed chronic pouchitis with mucosal edema, ulcers, and pouch stiffness. Due to medical refractoriness and timing, we believed that her CARP resulted from herniorrhaphy with mesh placement. She underwent diversion ileostomy, adhesiolysis, and mesh removal in August, 2014. The pouchitis symptoms resolved without further medical therapy. She underwent ileostomy reversal in December, 2014 and was without clinical or endoscopic recurrence of pouchitis and has been doing well ever since. This is the first documented association of abdominal herniorrhaphy with mesh placement and CARP in the medical literature. Despite unclear pathogenesis, a variant of ischemic pouchitis due to chronic compromise of mesenteric blood flow or foreign body reaction is possible. Risks and benefits of herniorrhaphy with mesh placement in patients with ileal pouch must be carefully balanced.Figure 1Figure 2Figure 3