Endoscopic Evaluation of the Ileal Pouch

Abstract

BACKGROUND: Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and ileal pouch-anal anastomosis. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE: A systemic review of the literature was performed and principles and techniques of pouchoscopy were described. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between Jan 2000 and May 2023 were including based on PRISMA guidelines. INTERVENTION: Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accurate characterization of the ileal pouch at the healthy or diseased states. RESULTS: The main anatomic structures of a J or S pouch are the stoma closure site, prepouch ileum, inlet, tip of the “J,” pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the “J” and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS: This is a qualitative, not quantitative review of mainly case series. CONCLUSIONS: Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch, and recognize common abnormalities. See video from symposium. See Video.

Endoscopic plication for the treatment of twisted pouch

“…With unclear etiopathogenesis, pouch volvulus or axial pouch twist is a rare complication of IPAA. The estimated frequency is 0.18% (3/1,700) [ 5 ]. While surgery has been considered standard care, endoscopic decompression and detortion are used for temporary symptom relief and provide a bridge for subsequent therapy [ 5 ].…”

“…The estimated frequency is 0.18% (3/1,700) [ 5 ]. While surgery has been considered standard care, endoscopic decompression and detortion are used for temporary symptom relief and provide a bridge for subsequent therapy [ 5 ]. In patients with partial pouch twist and absence of ischemia or necrosis, more definitive endoscopic therapy can be attempted.…”

“…Twisted pouch or pouch volvulus is a clinical phenotype of floppy pouch complex [ 2 , 3 ]. Pouchoscopy and pouchogram are the main modalities for the diagnosis [ 4 , 5 ]. Twisted pouch has traditionally been treated with surgical de-rotation, pexy, pouch redo, or excision [ 2 , 6–8 ].…”

“…Twisted pouch has traditionally been treated with surgical de-rotation, pexy, pouch redo, or excision [ 2 , 6–8 ]. Patients are at risk of postoperative recurrence or pouch excision [ 4 , 5 ]. Less invasive, endoscopic approaches have been performed for the treatment of twisted pouches such as septectomy [ 9 ].…”

Solitary pouch ulcer syndrome—a newly recognized phenotype of the ileal pouch disorders

“…Patients can present with symptoms of chronic antibiotic-dependent pouchitis, dyschezia, bleeding, and anemia. A combined endoscopic, histologic, radiographic, and manometric evaluation is required for the diagnosis and disease monitoring [ 5 ]. Endoscopic examination often shows solitary ulcer(s) in the distal pouch fold(s).…”