Ileo-anal pouch necrosis secondary to small bowel volvulus: A case report
© Patel et al; licensee BioMed Central Ltd. 2008
Received: 12 February 2008
Accepted: 30 May 2008
Published: 30 May 2008
Small bowel volvulus is a rare occurrence in the Western world and its occurrence after ileo-anal ouch formation is even rarer.
We report a case of a 26 year old lady who presented with small bowel volvulus and subsequent ischaemia and necrosis of her ileo-anal pouch created 5 years previously.
This case illustrates a rare but potentially devastating complication of ileo-anal pouch formation and as such the diagnosis should be borne in mind when a patient with a pouch presents with an acute abdomen.
Small bowel volvulus (SBV) as a cause of intestinal obstruction is an uncommon surgical emergency. It is a recognised entity in neonates associated with abnormal midgut rotation[1, 2], but is seldom seen in adults. Delayed diagnosis may lead to bowel ischaemia, infarction and consequent morbidity. We describe a case of acute small bowel volvulus and resultant pouch necrosis in a patient who had previously undergone total colectomy with ileo-anal pouch formation.
SBV is a rare cause of small bowel obstruction in the West with a reported incidence of 1.7–5.7 cases per 100,000 habitants and an associated mortality rate of upto 35%. Primary SBV occurs when the small bowel rotates around its mesentery (in the absence of congenital or adhesive bands) causing interruption to the blood supply to and from the bowel resulting in venous congestion, obstruction, ischaemia and eventual necrosis. Various aetiological factors have been proposed in its development as a primary condition including diet and changes in gut motility. Observational studies have noted an increased incidence of the condition during periods of feasting in the Third World where after starvation large amounts of food are rapidly ingested. The displacement of the jejunum into the pelvis by a large food bolus may cause the empty small bowel to move proximally within the abdomen and cause volvulus. This requires the presence of a short and broad mesentery and firm abdominal wall muscles to prevent coronal movement of the bowel.
Changes in gut motility and tone have also been implicated in the formation of primary volvulus. Chaussade et al reported the presence of increased discrete clustered contractions after small bowel anastomosis to the anal sphincter, possibly as a consequence of functional obstruction. Alterations in the levels of the gut motility stimulant 5-hydroxy-tryptamine (5-HT), as well as diabetic autonomic neuropathy have also been implicated[8, 9].
Secondary SBV is more commonly seen in the West and can develop as a result of twisting of the small bowel around a fixed point that may have arisen due to adhesions, internal herniation , or Meckel's diverticulum. An association between SBV and large small bowel diverticula (>3 cm) has also been noted  as well as an isolated report of SBV secondary to a migrating mesh plug. The alteration of the relationship of the superior mesenteric artery to its corresponding vein, as a result of torsion of the mesentery around its attachment, and the associated 'swirl sign' are important markers of SBV.
Ileo-anal pouch formation is a commonly performed procedure for patients with ulcerative colitis to maintain faecal continence following colectomy. Complications of the procedure include the development of cuff abscess, pouch leak, strictures, fistulation, stenosis, and pouchitis. Small bowel obstruction as a complication of ileo-anal pouch formation has been described in the literature, and is usually a result of post-operative adhesions either within the pelvis, or at the site of the covering ileostomy[17–20]. The development of pouch ischaemia and necrosis following small bowel volvulus however is a rare complication with only one reported case identified with classical radiological 'corkscrew' findings as apparent in our case. This diagnosis should therefore be considered in patients presenting with small bowel obstruction following ileo-anal pouch procedures.
The patient concerned has given her full informed consent for the use of all radiology and pictures and the case history in the production of this paper
- Iwuagwu O, Deans GT: Small bowel volvulus: a review. J R Coll Surg Edinb. 1999, 44 (3): 150-155. 1999/06/18PubMedGoogle Scholar
- Shimanuki Y, Aihara T, Takano H, Moritani T, Oguma E, Kuroki H, Shibata A, Nozawa K, Ohkawara K, Hirata A, Imaizumi S: Clockwise whirlpool sign at color Doppler US: an objective and definite sign of midgut volvulus. Radiology. 1996, 199 (1): 261-264. 1996/04/01View ArticlePubMedGoogle Scholar
- Welch GH, Anderson JR: Volvulus of the small intestine in adults. World J Surg 1986/06/01 edition.1986, 10 (3): 496-500. 10.1007/BF01655319.View ArticlePubMedGoogle Scholar
- Duke JH, Yar MS: Primary small bowel volvulus: cause and management. Arch Surg 1977/06/01 edition. 1977, 112 (6): 685-688.View ArticlePubMedGoogle Scholar
- McDonald IO, Hawker DB: Small bowel volvulus - the commonest abdominal emergency in Nepal. Bristol Med Chir J 1980/01/01 edition. 1980, 95 (355-356): 4-8.PubMedGoogle Scholar
- Vaez-Zadeh K, Dutz W, Nowrooz-Zadeh M: Volvulus of the small intestine in adults: a study of predisposing factors. Ann Surg 1969/02/01 edition. 1969, 169 (2): 265-271. 10.1097/00000658-196902000-00014.PubMed CentralView ArticlePubMedGoogle Scholar
- Chaussade S, Merite F, Hautefeuille M, Valleur P, Hautefeuille P, Couturier D: Motility of the jejunum after proctocolectomy and ileal pouch anastomosis. Gut 1989/03/01 edition. 1989, 30 (3): 371-375. 10.1136/gut.30.3.371.PubMed CentralView ArticlePubMedGoogle Scholar
- Freund H: Volvulus of the small bowel in a diabetic patient. Br Med J 1976/09/11 edition. 1976, 2 (6036): 641.PubMed CentralView ArticlePubMedGoogle Scholar
- De Souza LJ: Volvulus of the small bowel. Br Med J 1976/05/01 edition. 1976, 1 (6017): 1055-1056.PubMed CentralView ArticlePubMedGoogle Scholar
- Catalano O: Small bowel volvulus following ileal pouch-anal anastomosis: CT demonstration. Eur J Radiol 1996/09/01 edition. 1996, 23 (2): 115-117. 10.1016/0720-048X(96)01065-0.View ArticlePubMedGoogle Scholar
- Khanna A, Newman B, Reyes J, Fung JJ, Todo S, Starzl TE: Internal hernia and volvulus of the small bowel following liver transplantation. Transpl Int 1997/01/01 edition. 1997, 10 (2): 133-136.PubMed CentralView ArticlePubMedGoogle Scholar
- D'Souza CR, Kilam S, Prokopishyn H: Axial volvulus of the small bowel caused by Meckel's diverticulum. Surgery 1993/11/01 edition. 1993, 114 (5): 984-987.PubMedGoogle Scholar
- Chou CK, Mark CW, Wu RH, Chang JM: Large diverticulum and volvulus of the small bowel in adults. World J Surg 2004/12/16 edition. 2005, 29 (1): 80-82. 10.1007/s00268-004-7454-9.View ArticlePubMedGoogle Scholar
- Stout CL, Foret A, Christie DB, Mullis E: Small bowel volvulus caused by migrating mesh plug. Am Surg 2007/09/21 edition. 2007, 73 (8): 796-797.PubMedGoogle Scholar
- Loh YH, Dunn GD: Computed tomography features of small bowel volvulus. Australas Radiol 2000/12/05 edition. 2000, 44 (4): 464-467. 10.1046/j.1440-1673.2000.00856.x.View ArticlePubMedGoogle Scholar
- Dayton MT, Larsen KR, Christiansen DD: Similar functional results and complications after ileal pouch-anal anastomosis in patients with indeterminate vs ulcerative colitis. Arch Surg 2002/06/07 edition. 2002, 137 (6): 690-4; discussion 694-5. 10.1001/archsurg.137.6.690.View ArticlePubMedGoogle Scholar
- Aberg H, Pahlman L, Karlbom U: Small-bowel obstruction after restorative proctocolectomy in patients with ulcerative colitis. Int J Colorectal Dis 2006/11/15 edition. 2007, 22 (6): 637-642. 10.1007/s00384-006-0215-5.View ArticlePubMedGoogle Scholar
- Marcello PW, Roberts PL, Schoetz DJ, Coller JA, Murray JJ, Veidenheimer MC: Obstruction after ileal pouch-anal anastomosis: a preventable complication?. Dis Colon Rectum 1993/12/01 edition. 1993, 36 (12): 1105-1111. 10.1007/BF02052257.View ArticlePubMedGoogle Scholar
- MacLean AR, Cohen Z, MacRae HM, O'Connor BI, Mukraj D, Kennedy ED, Parkes R, McLeod RS: Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg 2002/01/25 edition. 2002, 235 (2): 200-206. 10.1097/00000658-200202000-00007.PubMed CentralView ArticlePubMedGoogle Scholar
- Francois Y, Dozois RR, Kelly KA, Beart RW, Wolff BG, Pemberton JH, Ilstrup DM: Small intestinal obstruction complicating ileal pouch-anal anastomosis. Ann Surg 1989/01/01 edition. 1989, 209 (1): 46-50. 10.1097/00000658-198901000-00007.PubMed CentralView ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.