26 Pouch Volvulus in Pregnancy: A Rare Diagnostic and Therapeutic Challenge

Background: Total proctocolectomy and ileoanal pouch anastomosis (IPAA) also known as J-pouch surgery, is a surgery that is used to restore gastrointestinal continuity in patients with ulcerative colitis (UC) and familial adenomatous polyposis after colon and rectum are removed. Common complications after IPAA include pouchitis, anastomotic leak, pouch obstruction and rarely pouch twisting or volvulus. Obstruction secondary to pouch volvulus is exceedingly rare. Here we report a case of IPAA leading to obstruction and subsequent perforation in a pregnant woman, which requires clinical vigilance and early intervention. Case Description: A 26-year-old female with pertinent history of primary sclerosing cholangitis and UC since 2014 complicated by multifocal low-grade dysplasia status post IPAA in 2023 and chronic pouchitis with 11 weeks gestation was transferred from outside hospital due to abdominal pain. MRI of abdomen and pelvis (MRI AP) without IV contrast at outside hospital revealed a large stool burden in the J pouch and moderate distention of the upstream distal small bowel. Exam reviewed distal anastomotic stricture requiring manual dilation of stricture and pouch contents successfully evacuated; however, symptoms persisted, prompting transfer. Patient had stable vital signs and diffuse abdominal tenderness without guarding. Pouchoscopy showed distal anastomotic stricture which was dilated digitally, erythematous mucosa in J pouch and stricture at the ileoanal anastomosis, and evidence of twisting at distal pouch which was reduced with insertion of endoscope. Stricture dilated to with through the scope balloon to 12 mm and colonic decompression tube was placed. Worsening clinical symptoms prompting repeat MRI AP showing swirling of J pouch in the lower pelvis and new fluid collections in the pelvis, concerning for perforation (likely at the time of pouchoscopy with dilation). Patient subsequently underwent urgent exploratory laparotomy with small bowel resection due to mesentery twisting and herniation of small bowel and loop end ileostomy with pouch left in situ. Due to ongoing pouch retention of contents (due to persistent pouch volvulus at the distal anastomosis) a rectal stent was placed for improved depression. This was later removed and replaced with a malecot catheter sutured in place for continue decompression. At most recent follow-up patient is 32 weeks estimated gestation age and clinically well with ongoing rectal drainage consistent with pouch outlet patency due to catheter. Conclusions: Pouch volvulus is a rare but serious complication following proctocolectomy with IPAA. It typically presents with acute abdominal pain, distention and obstipation. Diagnosis is challenging with CT being the preferred modality for identifying volvulus and assessing viability. Risk factors include laparoscopic reconstruction due to less adhesions, female, low body mass index and anterior positioning of the pouch mesentery. Management involves early recognition and surgical interventions as definite treatment. Due to its rarity, there are only limited case reports describing pouch volvulus. Our case contributes to this scare body of literature, with the additional complexity of pregnancy status further complicating both diagnosis and management options.