Pouch Volvulus in Patients Having Undergone Restorative Proctocolectomy for Ulcerative Colitis: A Case Series

BACKGROUND: Restorative proctocolectomy with IPAA improves quality of life in patients with medically refractory ulcerative colitis. Although bowel obstruction is common, pouch volvulus is rare and described only in case reports. Diagnosis can be challenging, resulting in delayed care and heightened morbidity. OBJECTIVE: The purpose of this study was to delineate the symptoms and successful management strategies used in patients with IPAA volvulus that result in pouch salvage. DESIGN: This study was a case series. SETTINGS: The study was conducted at a tertiary referral center for ulcerative colitis in Milwaukee, Wisconsin. PATIENTS: Patients included those with volvulus of the IPAA. MAIN OUTCOME MEASURES: Over the study period (2010-2015), 6 patients were diagnosed with IPAA volvulus. The primary outcomes were symptom manifestation, diagnostic practices, and treatment of pouch volvulus. RESULTS: Six patients with ulcerative colitis were identified with pouch volvulus. The majority (n = 4) underwent a laparoscopic pouch creation and had early symptom manifestation after surgery. Complications preceding volvulus included pouch ulceration (n = 5) and pouchitis (n = 4). The most common presenting symptoms of volvulus were abdominal pain (n = 4) and obstipation (n = 4). Multiple imaging modalities were used, but volvulus was most frequently identified by CT scan. Management was primarily operative (n = 5), composed of excision of the pouch (n = 3), pouch-pexy (n = 1), and detorsion with defect closure (n = 1). Both operative and nonoperative treatment with endoscopic detorsion resulted in low morbidity and improved patient symptoms. LIMITATIONS: This single-institution study is limited by its retrospective design and small number of patients. CONCLUSIONS: IPAA volvulus is a rare and challenging cause of bowel obstruction in ulcerative colitis. Heralding signs and symptoms, such as pouch ulceration and acute obstipation, should initiate a workup for a twisting pouch. Diagnosis, which is multimodal, must occur early to avert necrosis and allow for preservation of a well-functioning pouch. See Video Abstract at http://links.lww.com/DCR/A561.