SCIENTIFIC
Complications After Ileostomy Reversal: Internal Hernia and Volvulus in a Gardner Syndrome Patient with Ileal Pouch Anal Anastomosis
AUTHORS:
ABSTRACT
Hakam Rajjoub, BS 1 Justin J. Williams, BS 1 Emily Groves, MD 2 Kevin Train, MD 2
AFFILIATIONS:
1
West Virginia University School of Medicine, Medical Student
2
West Virginia University Department of Surgery, Division of Colon and Rectal Surgery, Assistant Professor
CORRESPONDING AUTHOR:
Justin J. Williams, BS jw016 @ mix. wvu. edu
DISCLOSURES: None
ETHICS STATEMENT:
Permission from the patient has been obtained.
FUNDING: None
ACKNOWLEDGMENTS:
Jennifer Plymale and Amber Vance at the Robert C. Byrd Center for Rural Health
FIGURE 1
We present the case of a 19-year-old male with Gardner syndrome, status post total proctocolectomy and ileal pouch-anal anastomosis( IPAA) at 8 years of age, who developed an internal hernia and volvulus more than 10 years following ileostomy reversal. Patients with a history of total proctocolectomy and IPAA are at an increased risk for long-term complications such as internal hernias and volvulus due to altered anatomy and mesenteric defects. Early imaging and prompt surgical intervention were crucial in preventing ischemia of the J-pouch and the possible need for a permanent ileostomy in our teenaged patient. This case describes a medical condition that has not been well characterized in the literature and emphasizes the importance of prolonged clinical vigilance and surveillance in post-IPAA patients, as mild symptoms may signal serious complications requiring urgent intervention, even many years after ileostomy reversal. bing, infraumbilical abdominal pain, accompanied by obstipation. A computed tomography( CT) scan revealed a small bowel obstruction in the mid-abdomen( Figure 1), with proximal dilation and a transition point, along with trace free fluid in the pelvis, which was considered physiologic. No evidence of pneumatosis or intra-abdominal free air were identified. Swirling of the mesentery was also noted, suggesting a possible internal hernia. On initial presentation to the emergency department, his abdominal examination revealed generalized tenderness without distension, and his vitals were within normal limits. Laboratory findings included a mildly elevated white blood cell count( 11.1 × 10⁹ / L) and a venous pH of 7.31, with normal serum lactate levels. Given his deteriorating clinical condition, urgent surgical intervention was performed.
During diagnostic laparoscopy, dilated small bowel loops were observed. The small intestine was traced from the ligament of Treitz to the pelvis, where feculent fluid was encountered. Conversion to an exploratory laparotomy confirmed a perforation at the internal hernia site, where proximal ileum had become trapped behind the mesentery of the
Deborah Preston at the Marshall University Joan C. Edwards School of Medicine Department of Pediatrics
Dr. Brandon J. Henderson and Nathan Olszewski at the Marshall University Department of Biomedical Sciences
CASE PRESENTATION
A A 19-year-old male with a history of Gardner syndrome, status post total proctocolectomy and ileal pouch-anal anastomosis( IPAA) with diverting loop ileostomy and subsequent ileostomy reversal at 8 years of age, presented with one day of sudden-onset, constant, stab-
Computed tomography of the abdomen, internal hernia, and small bowel obstruction: abnormally fluid-filled and dilated loops of the central small bowel, with a transition point identified in the distal small bowel, just proximal to the anastomosis, with some associated swelling of the mesentery.
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