Introduction: Total proctocolectomy with creation of a pouch using a loop of small bowel followed by Ileal pouch-anal anastomosis (IPAA) is a commonly performed surgical treatment for ulcerative colitis (UC). The surgery is usually performed in 3 stages, and the ‘J-type’ of pouch is the most commonly created pouch reservoir after proctocolectomy. If the pouch is anastomosed with a twist along its longitudinal axis it may lead to stenosis at the IPAA. Case Presentation: A 30 year old female with history of medically refractory UC underwent 3-staged total proctocolectomy and IPAA within a year since diagnosis. Two months after ileostomy closure, she developed partial small bowel obstruction as evidenced by abdominal CT scan which showed dilated loops of small bowel (>3 cm) with interloop pockets of ascites. Multiple pouchoscopies were performed which showed anastomotic obstruction, but no endoscopic therapy was given. A repeat pouchoscopy examination demonstrated partial stenosis at anastomosis which was in fact caused by twisted distal pouch along its longitudinal axis (Figure 1). There was no evidence of pouchitis but it appeared that the pouch had a twist creating a stenosis at the IPAA. An endoscopic needle knife (NK) with electroincision/cauterization was used and the apex of twisted pouch was incised in circumferential fashion (Figure 2). No significant bleeding was noted during and after the outpatient endoscopy procedure Within 1 day she had complete resolution of her GI symptoms and repeat pouchoscopy 2 weeks later showed resolution of the obstruction. Conclusions: Surgical proctocolectomy with IPAA is a technically challenging surgery and can sometimes lead to a twist in the pouch at time of anastomosis with anus. This can lead to stenosis at IPAA leading to incomplete pouch evacuation and small bowel obstruction. A therapeutic NK can be used for cutting the mucosal tissue at the apex of the twisted pouch near the IPAA, thereby releasing the stenosis.
