Acute abdomen due to J-pouch outlet obstruction: A case report and review of literature

INTRODUCTION: Ileal pouch–anal anastomosis is the procedure of choice for re-establishing intestinal continuity for patients undergoing total proctocolectomy. Despite growing experience with this procedure, it is still associated with considerable morbidity rates. PRESENTATION OF CASE: Herein, we report the case of a 14-year-old boy with familial adenomatous polyposis who underwent total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy. The patient developed early postoperative complications; on postoperative day 1, he developed bleeding from the pouch staple line, which was managed endoscopically. On postoperative day 15, he developed intestinal obstruction due to adhesions. One year after proctocolectomy, ileostomy closure was performed uneventfully. From postoperative day 3, the patient presented with obstructive signs such as abdominal distention, bloating, abdominal pain, and fever. Computed tomography identified diffuse intense intestinal distension with pouch dilatation. Digital rectal examination identified the pouch filled with liquid stool and no signs of anal canal anastomosis stenosis. The patient was considered to have pouch outlet obstruction and was successfully managed using bedside evacuation anoscopy. After 3 days, oral nutrition was re-established, and appropriate stool evacuation and fecal continence were achieved. DISCUSSION: Proctocolectomy with ileal pouch–anal anastomosis still carries a considerable complication rate. Proper identification of causative factors is mandatory for appropriate treatment. Pouch outlet obstruction can present as acute abdomen after diverting ileostomy closure. In this case, outlet obstruction was identified and treated by pouch evacuation, avoiding morbidity of a new surgical procedure. CONCLUSION: We presented an unusual case of acute intestinal obstruction due to pouch outlet obstruction that was managed nonoperatively with bedside pouch evacuation.