EP793 - J-Pouch Obstruction Secondary to External Compression from Gravid Uterus

Purpose/Background: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) has become the treatment of choice for surgical management of refractory ulcerative colitis (UC). Patients who undergo IPAA are at particularly high risk for small bowel obstruction given combined abdominal and pelvic dissection and the need for multiple staged operations. Small bowel obstruction is the most common complication after IPAA affecting about 13-35% of patients1. While adhesive disease is the most common etiology, it is important to consider a broad differential, including anastomotic stricture, functional obstruction, afferent limb obstruction, and extrinsic compression.

Methods/Interventions: .

Results/Outcomes: We present a 26-year-old female with history of UC for which she underwent a 3-stage restorative proctocolectomy. She presented seven months after her loop ileostomy reversal at 22 weeks gestation with 48 hours of abdominal pain, nausea/emesis, and obstipation. Imaging was suggestive of small bowel obstruction with transition point at the pouch-anal anastomosis. NG tube was placed for decompression and she underwent endoscopic evaluation which revealed no evidence of anastomotic stricture. The proximal end of the ileoanal pouch appeared to be extrinsically compressed. The next day she underwent laparoscopic single incision diverting loop ileostomy for management of her obstruction and to facilitate resumption of enteral nutrition to help support the patient and her growing fetus. Intra-operatively the gravid uterus was seen to be compressing the afferent limb of the J-pouch as it entered the pelvis. Post-operatively, NG tube was removed and she tolerated oral intake with appropriate ostomy output. She subsequently gave birth to a healthy child at term via C-section without complication. Postpartum, she had a pouchoscopy demonstrating healthy mucosa and a gastrografin enema with no evidence of stricture or ongoing extrinsic compression. She has since undergone ileostomy reversal and is currently doing well without any additional complication.

Conclusion/Discussion: Bowel obstruction during pregnancy is relatively uncommon and typically occurs secondary to adhesions from prior intra-abdominal surgery. Symptoms can be non-specific and a high index of suspicion is needed for early diagnosis, because bowel obstruction during pregnancy poses significant risk of morbidity and mortality for both the fetus and the mother. Our case highlights the importance of consideration of the rare diagnosis of extrinsic compression from a gravid uterus in the differential diagnosis of bowel obstruction in pregnant patients.

Figure 1
A) Axial view of transition point (yellow arrow) noted in afferent limb of J pouch in close proximity to gravid uterus. B) Coronal view of compressed afferent limb (red arrows) abutting gravid uterus. C) Endoscopic view of widely patent pouch-anal anastomosis. D) Endoscopic view of point of obstruction from apparent extrinsic compression from the gravid uterus.