Small Bowel Obstruction in Ileal J-pouch From Coin Ingestion

Abstract

Introduction Small bowel obstruction is a common complication after ileal J-pouch-anal anastomosis (IPAA). Adhesions are the most frequent cause. Foreign body ingestions are uncommon in adults. We report a rare case of a small bowel obstruction in an adult patient with IPAA after coin ingestion. Case Description A 72 year old man with history of refractory ulcerative colitis underwent protocolectomy with ileal J-pouch-anal anastomosis in 1999. He presented to the emergency department in December 2016 with complaint of crampy, lower abdominal pain, nausea and vomiting for two days. He denied any fever or chills. No constipation or diarrhea. Lab studies revealed a normal white blood cell count, normal lipase and normal liver function tests. CT scan of the abdomen revealed a dilatation of the distal ileum measuring 38 mm in diameter, small bowel wall thickening and mesenteric fat stranding proximal to the ilioanal anastomosis. Findings were concerning for small bowel obstruction with transition point at the ilioanal anastomosis. Patient underwent pouchoscopy which revealed erythematous mucosa in the j-pouch and presence of a severe stricture measuring about one cm in length and 7mm in diameter (Figure 1). The stricture was traversed after balloon dilation under fluoroscopic guidance (Figure 2). A United States penny coin was found proximal to the stricture which was retrieved from the j-pouch using a Roth Net® retriever (Figure 3). Patient had resolution of his symptoms after the procedure. Patient might have inadvertently swallowed the coin along with his daily pills which he routinely kept in his pants pocket. Discussion Coin and other foreign body ingestions are common in pediatric population but infrequent in adults. Swallowed items that pass beyond the pylorus are simply observed as they usually pass spontaneously through the gastrointestinal tract. Retained foreign bodies can increase the risk of complications by 50%, including formation of strictures, fistulas, abscesses, perforation, sepsis and death. It is estimated that up to 35% patients with IPAA experience small bowel obstruction most commonly due to extensive adhesions. It is possible that the high zinc content in the penny coin might have contributed to the inflammation and stricture formation in the j-pouch. Our case illustrates that retained foreign bodies can be safely and successfully removed endoscopically in patients with IPAA without need for open surgery.Figure: Balloon Stricture Dilation.Figure: Pre and Post Stricture Dilation.Figure: Coin in proximal J-pouch.