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Crohn's Disease in the Ileal Pouch After Total Colectomy for Ulcerative Colitis: Findings on Pouch Enemas in Six Patients

Nicolaus A. Wagner-Bartak1, Marc S. Levine1, Stephen E. Rubesin1, Igor Laufer1, John L. Rombeau2 and Gary R. Lichtenstein3

1 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
2 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
3 Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.



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  		Fig. 1. —26-year-old man with Crohn's disease in ileal pouch and distal ileum after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis. Shallow right posterior oblique spot image from single-contrast pouch enema with barium shows cobblestoning of distal ileum (white arrows) with obliteration of normal fold pattern. Note dilatation of ileum more proximally. Also note irregular contour of pouch (black arrows) secondary to multiple tiny ulcers. This patient was treated with antibiotics, immunosuppressive agents, steroids, and infliximab.

 


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  		Fig. 2. —39-year-old man with Crohn's disease in ileal pouch and distal ileum after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis. Steep right posterior oblique spot image from single-contrast pouch enema with barium shows narrowing and ulceration of distal ileum (small black arrows) abutting pouch (large black arrow). Note other narrowed ileal loops (white arrows) involved by Crohn's disease more proximally. Other views showed associated inflammation of pouch. This patient underwent excision of the pouch with a permanent end ileostomy.

 


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  		Fig. 3. —53-year-old man with Crohn's disease in ileal pouch and distal ileum after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis. Left lateral spot image from single-contrast pouch enema with barium shows end-to-side ileal-pouch anastomosis with stricture (large black arrow) extending from proximal end of pouch into adjacent ileum. Two additional strictures are shown more proximally in ileum (small white arrow) and in blind-ending ileal stump (large white arrow). Also note small ulcers (small black arrow) in distal ileum abutting pouch. This patient was treated with antibiotics and infliximab.

 


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  		Fig. 4. —34-year-old woman with Crohn's disease in ileal pouch after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis. Shallow right posterior oblique spot image from pouch enema with water-soluble contrast material shows marked narrowing and deformity of distal end of pouch and region of ileoanal anastomosis (black arrows) with small extraluminal collections and sinus tracks (white arrows) extending into perineum. This patient was treated with steroids, immunosuppressive agents, and infliximab, followed by excision of the pouch with a permanent end ileostomy.

 

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