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Description
Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with refractory ulcerative colitis. Long-term complications of this procedure include pouchitis, metabolic complications, strictures, fistulae, pouch failure and pouch neoplasia.1 ,2 One series of 1911 patients with ileal pouch-anal anastomosis found a 3.5% failure rate at 5.5 years with causes including: pelvic sepsis, high stool volume, incontinence and disease remission.3 We present a rare case of massive abdominal distension due to non-functioning of the pouch necessitating complete excision of the pouch with end ileostomy to alleviate intractable symptoms.
A 73-year-old woman with a history of ulcerative colitis and colectomy with ileoanal pouch formation almost 30 years prior was experiencing chronic abdominal distension, diarrhoea and malnutrition. She had lost 10 kg over 1 year and her body mass index had dropped to 15 kg/m2. Examination revealed a hugely distended abdomen with visible peristalsis and tympanic resonance on percussion. Imaging demonstrated a grossly distended pouch and proximal bowel dilation (figures 1 and 2). Excision of the non-functional pouch was performed via a midline laparotomy. Findings were an abnormally dilated non-functional pouch with an approximate size of 44×22 cm (figure 3), and grossly dilated small bowel up to the proximal jejunum with no point of obstruction. The pouch was mobilised up to the pelvic floor and completely excised at the anorectal junction. A defunctioning right iliac fossa ileostomy was fashioned. Postoperatively, a prolonged stay on intensive care was necessary due to difficulty weaning from mechanical ventilation. The patient went on to make a good recovery.
Learning points
Chronic distension of an ileoanal pouch can lead to malabsorption syndrome.
Complete excision of the pouch with creation of a defunctioning end ileostomy may be curative in such patients.
Abdominal radiograph demonstrating hugely dilated ileoanal pouch with proximal small bowel dilation.
Sagittal view of CT scan demonstrating the extent of this massively distended ileoanal pouch.
Intraoperative photograph demonstrating chronically distended, large, non-functional ileoanal pouch with dilation of the proximal small bowel.
Footnotes
Contributors PCC wrote the article, and RT and AA reviewed the article.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.