MRI of the ileal pouch

Ileal pouch surgery is the surgical gold standard treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, ileal pouch surgery is a technically challenging procedure and is associated with high morbidity. Clinical presentations of pouch complications are often nonspecific but imaging can identify many of these complications and is essential in clinical management. This paper will focus on magnetic resonance imaging (MRI) of the ileal pouch, including recommended MRI protocol and approach to imaging interpretation with an emphasis on those ileal pouch complications particularly well evaluated with MRI.

Contrast enema, CT, and small bowel series of the ileal pouch

This manuscript is part of the ileal pouch symposium and will describe the water-soluble contrast enema, CT, and small bowel series. MRI and other imaging modalities are discussed elsewhere in the symposium. Water-soluble contrast enema and CT are excellent for the evaluation of the ileal pouch. Contrast enema and CT with anal contrast administration can allow for anastomotic integrity and pouch assessment. Pre-pouch ileum, extra-intestinal manifestations, and acute symptomatology are best assessed with CT. The contrast small bowel examination is of limited utility in pouch patients and should not be performed. Indications, imaging technique, and anatomic pouch assessment with water-soluble contrast enema, CT, and contrast small bowel examination will be reviewed here.

Surgical Management of Ulcerative Colitis

Ulcerative colitis can be managed by surgical resection of the colon and rectum. The final reconstruction options of traditional end ileostomy, continent ileostomy, ileorectal anastomosis, or ileal pouch anal anastomosis (IPAA). We maintain that the IPAA is the gold standard management of ulcerative colitis and should be performed in stages. This article includes descriptions of technique, management alternatives, and intraoperative and postoperative management of pouch issues.

Outcomes after ileal pouch anal anastomosis in patients with primary sclerosing cholangitis

BACKGROUND AND AIMS

Outcomes after ileal pouch anal anastomosis (IPAA) are not well established in patients with primary sclerosing cholangitis (PSC). We conducted a comprehensive outcomes assessment in these patients.

METHODS

A retrospective case note review of complications in all PSC-IPAA (n=21) and matched ulcerative colitis patients with IPAA (UC-IPAA; n=79) after surgery in Oxford (1983-2012) was conducted, and functional outcomes (Öresland score) were evaluated (2012). Quality of life [Cleveland Global Quality of Life Questionnaire, Short Form-36 (SF-36)], and sexual function were also assessed (2012) including patients with PSC-associated UC without IPAA (PSC-UC; n=19). Sub-group analysis of patients with large duct (ld) PSC-IPAA (n=17) was also performed.

RESULTS

The 1-, 5-, 10- and 20-year risk of acute pouchitis for PSC-IPAA was 10%, 19%, 31% and 65% respectively, compared to 3%, 10%, 14% and 28% in UC-IPAA (p=0.03). More PSC-IPAA (36%) had poor nocturnal pouch function (vs 2% in UC-IPAA; p=0.0016). There were no differences in surgical complications, quality of life or sexual function between the 3 main groups. LdPSC-IPAA had poorer pouch function (Öresland score: 7.7 vs 5.4 in UC-IPAA; p=0.02), and worse quality of life [SF-36 Physical: 42 vs 50.5 in UC-IPAA; 47.7 in PSC-UC; p=0.03 and Mental Health summary scores: 41.6 vs 51.2 in UC-IPAA; 42.3 in PSC-UC; p=0.04].

CONCLUSIONS

PSC-IPAA suffer more acute pouchitis and have worse functional outcomes than UC-IPAA. LdPSC-IPAA also have poorer quality of life.