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Utility of Contrast Enema for Detecting Anastomotic Strictures After Total Proctocolectomy and Ileal Pouch–Anal Anastomosis

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 19104.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —53-year-old woman who underwent normal water-soluble contrast enema after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral (A), frontal (B), and steep oblique (C) spot images of pelvis before takedown of diverting ileostomy show normal appearance of ileal pouch and ileoanal anastomosis (white arrows), which has smooth, symmetric margins and diameter of 20 mm. Note dilatation of anal canal distal to anastomosis, a common finding on these studies. In A and C, tip of catheter (black arrows) is in ileal pouch, whereas in B, tip of catheter (black arrow) is just distal to ileoanal anastomosis.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —53-year-old woman who underwent normal water-soluble contrast enema after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral (A), frontal (B), and steep oblique (C) spot images of pelvis before takedown of diverting ileostomy show normal appearance of ileal pouch and ileoanal anastomosis (white arrows), which has smooth, symmetric margins and diameter of 20 mm. Note dilatation of anal canal distal to anastomosis, a common finding on these studies. In A and C, tip of catheter (black arrows) is in ileal pouch, whereas in B, tip of catheter (black arrow) is just distal to ileoanal anastomosis.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —53-year-old woman who underwent normal water-soluble contrast enema after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral (A), frontal (B), and steep oblique (C) spot images of pelvis before takedown of diverting ileostomy show normal appearance of ileal pouch and ileoanal anastomosis (white arrows), which has smooth, symmetric margins and diameter of 20 mm. Note dilatation of anal canal distal to anastomosis, a common finding on these studies. In A and C, tip of catheter (black arrows) is in ileal pouch, whereas in B, tip of catheter (black arrow) is just distal to ileoanal anastomosis.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —50-year-old woman with stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Frontal spot image of pelvis from water-soluble contrast enema before closure of diverting ileostomy shows stricture at ileoanal anastomosis (white arrow), which has diameter of 8 mm. Note how tip of catheter (black arrow) is just distal to ileoanal anastomosis.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —50-year-old woman with stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Frontal spot image of pelvis from repeat water-soluble contrast enema after takedown of ileostomy shows continued stricture at ileoanal anastomosis (arrow) with marked dilatation of ileal pouch and reflux of contrast material into dilated loops of distal ileum. This patient presented with symptoms of obstruction (nausea, vomiting, and abdominal distention) after ileostomy closure.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —27-year-old woman with stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral spot image of pelvis from water-soluble contrast enema before closure of diverting ileostomy shows stricture at ileoanal anastomosis (white arrow), which has diameter of 4 mm. Note how tip of catheter (black arrow) is distal to ileoanal anastomosis.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —27-year-old woman with stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral spot image of pelvis from repeat water-soluble contrast enema after takedown of ileostomy shows continued stricture at ileoanal anastomosis (arrow), with dilatation of ileal pouch and retained debris in pouch. This patient presented with symptoms of obstruction (constipation and pelvic pain) after ileostomy closure.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —45-year-old man with false-positive stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral (A) and frontal (B) spot images of pelvis from water-soluble contrast enema before takedown of diverting ileostomy show apparent stricture at ileoanal anastomosis (arrows), which has diameter of 8 mm. However, patient had no clinical signs of obstruction after ileostomy closure, and no further imaging studies were performed. This was one of three false-positive anastomotic strictures in our study.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —45-year-old man with false-positive stricture at ileoanal anastomosis after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Lateral (A) and frontal (B) spot images of pelvis from water-soluble contrast enema before takedown of diverting ileostomy show apparent stricture at ileoanal anastomosis (arrows), which has diameter of 8 mm. However, patient had no clinical signs of obstruction after ileostomy closure, and no further imaging studies were performed. This was one of three false-positive anastomotic strictures in our study.

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