pouch( Figures 2a and 2b). In addition, the ileostomy reversal anastomosis had become patulous and fluid-filled, leading to volvulus formation. The internal hernia was reduced, and a small bowel resection with primary anastomosis was performed at the site of the perforation. The previous ileostomy reversal anastomosis was also resected. SPY angiography, an intraoperative fluorescence imaging technique used to assess tissue
Internal hernia.
FIGURE 2A
FIGURE 2B
Patulous previous ileostomy reversal anastomotic lead point. perfusion, confirmed adequate perfusion at the resected sites, and a side-to-side functional end-to-end anastomosis was performed at both sites. A flexible sigmoidoscopy confirmed that the J-pouch was healthy and well perfused.
The patient’ s initial recovery was uneventful, and he was discharged on post-operative day 5 after advancing his diet. However, he was readmitted on post-operative day 8 with nausea and vomiting following a meal. Imaging, including an abdominal radiograph and CT scan, revealed dilated bowel loops and mild pneumoperitoneum, consistent with postoperative changes. A nasogastric tube was placed for 24 hours, and his diet was gradually advanced as tolerated. A downward trend in white blood cell count and C-reactive protein confirmed clinical improvement, and he was discharged upon return of consistent bowel function.
Pathology from the resected ileostomy anastomosis showed focal mucosal ischemic changes, submucosal vascular congestion, and villous blunting. The specimen from the perforation site demonstrated focal mucosal ischemic changes, focal ileitis, and intraluminal neutrophilic debris, consistent with small bowel perforation. Submucosal congestion was noted, and the margins were viable with focal ileitis.
DISCUSSION
This case presents a rare instance of volvulus and internal hernia in a patient with Gardner syndrome who had undergone total proctocolectomy and IPAA with ileostomy reversal at age 8 years. Bowel perforation and volvulus typically present with severe symptoms such as excruciating pain, yet this patient initially had only mild symptoms despite a significant bowel obstruction. Early imaging in cases like this is therefore important, especially in high-risk patients, as subtle symptoms can mask serious underlying pathology. 1, 2 The more than 10-year interval between ileostomy reversal and volvulus and internal hernia presentation is also exceptional and has not been well described in the existing literature. Additionally, the larger anastomotic opening likely contributed to the formation of an internal hernia. Both factors combine to enhance the current understanding of the long-term anatomic risks in patients who have undergone IPAA and demonstrate the importance of continued clinical vigilance far beyond the initial postoperative period.
Gardner syndrome, a subtype of familial adenomatous polyposis, is an autosomal dominant disorder caused by mutations in the adenomatous polyposis coli gene, a tumor suppresser that regulates cell growth and adhesion. 3 These mutations lead to uncontrolled cell proliferation, significantly increasing the risk of colorectal cancer and extracolonic manifestations such as desmoid tumors, osteomas, and small bowel neoplasms. Patients with Gardner syndrome often undergo extensive surgical interventions, including IPAA, as was the case with this patient. 4 These surgeries, while necessary to manage malignancy risk, increase the likelihood of long-term complications such as internal hernias. The risk of internal hernia is further compounded by prior surgeries, such as ileostomy reversal, which can create weak points in the abdominal wall or mesentery, predisposing patients to volvulus. 5
Volvulus and internal hernias are rare but serious complications in patients with prior gastrointestinal surgeries, such as IPAA, where altered anatomy and mesenteric defects increase the risk of small bowel obstruction and perforation. 6-8 The risk of small bowel obstruction in IPAA patients exceeds 30 % within 10 years of surgery. 9 In this case, the volvulus developed at the ileostomy reversal site, a known point of weakness, and initially presented with mild symptoms, which obscured the extent of the obstruction and delayed intervention. While volvulus is often associated with severe pain and bowel ischemia, post-surgical patients may not follow typical clinical patterns, requiring a high index of suspicion. 2, 4 Imaging abnormalities warrant urgent intervention to prevent progression to ischemia, necrosis, or bowel perforation, which can compromise the J-pouch and require creation of a permanent ostomy. This can be particularly life-altering for young patients. Proactive management is critical in this
West Virginia Medical Journal • March 2026 • 23