An ileo-anal pouch doing the twist (with video)

A 37-year-old female patient had a past history of proctocolectomy for Crohn's disease, with ileal J-pouch-anal anastomosis. She was admitted for acute obstructive symptoms. CT scan revealed a 180 twisted ileo-anal anastomosis without signs of severe ischemia (Fig. 1 and video), prompting urgent endoscopic treatment. Lower endoscopy showed a complete spiral of the J-pouch which was easily untwisted and passed. Aspiration followed by placement of a multiperforated Faucher tube allowed immediate symptoms relief. The tube was withdrawn 2 days later and the patient was discharged on the same evening. Although the patient was warned for recurrences, no further episode had occurred at last (60 days) follow-up.

The term "twisted syndrome" refers to the twisting of the ileal pouch around its mesenteric axis, creating a volvulus, possibly leading to acute intestinal obstruction. It is often caused by insufficient adhesion of the ileum to the pelvis or to excessive length of the mesentery. If untreated, the twist can disrupt vascularization, leading to pouch ischemia and necrosis. The treatment typically involves emergency endoscopy to untwist the pouch whereas redo pouch-surgery should be discussed to prevent future episodes. Other mechanisms of pouch obstruction include prolapse (also known as “floppy pouch complex”) [2], inflammation, fibrosis, dysplasia or cancer related to inflammatory bowel disease, or rare extraluminal causes.

This case highlights the importance of combining emergency CT-scan and endoscopy to diagnose various pouch complications, to untwist the pouch in case of a volvulus, and to enhance the strategy for pouch salvage. Three-dimensional CT-based pouchography is also an advanced option to better guide decisions [3].