PDF herunterladen
Open Access
CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1811570
Learning Images

Multimodal Ultrasound-Guided Hybrid Endoscopic Therapy Averting Pouch Excision and Permanent Stoma in Crohn's Disease of the Pouch

Authors

  • Partha Pal 

    1   Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

  • Mohammad Abdul Mateen

    2   Department of Diagnostic Radiology and Imaging, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

  • Pradeep Rebala

    3   Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

  • Rajesh Gupta

    1   Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

  • Manu Tandan

    1   Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

  • D. Nageshwar Reddy

    1   Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

Funding None.
Weitere Informationen
Auch verfügbar auf
  Lizenzen und Reprints
Preview

Introduction

A 47-year-old woman with a history of ileal pouch-anal anastomosis (IPAA) for ulcerative colitis 2 years ago presented with rectal bleeding, obstructive symptoms, and feculent vaginal discharge. She had a prior history of pouchitis treated with multiple courses of antibiotics, steroids, and azathioprine.

Transabdominal ultrasound (TAS) revealed a thickened pre-pouch ileal loop, with modified Limberg 3 vascularity, edema, and loss of mural stratification, stricture with prestenotic dilation ([Fig. 1A]). Transperineal ultrasound (TPUS) with a linear probe demonstrated a low anovaginal fistula ([Fig. 1B]) and associated thickening in the pouch and pre-pouch ileum, confirmed on transrectal ultrasound.

Zoom
Fig. 1 Multimodal imaging and hybrid endoscopic management of Crohn's disease of the pouch. (A) Transabdominal ultrasound showing a short segment pre-pouch ileal stricture (left) with proximal prestenotic dilation (right). (B) Transperineal ultrasound (color Doppler mode) revealing an anovaginal fistula tract traversing between the anal canal and vagina, alongside a thickened ileal pouch wall. (C) Endoscopic image showing a tight stricture at the entry of the pouch being treated with endoscopic stricturotomy using an insulated-tip knife. (D) Balloon dilation of proximal ulcerated pre-pouch ileal stricture performed after partial stricturotomy with IT knife, under direct endoscopic visualization.

Pouchoscopy using a gastroscope (GIF-H190, Olympus Medical Systems, Tokyo, Japan) showed a double lumen above the pouch-anal anastomosis, with one strictured lumen leading into the pouch and a probable false tract. The fistulous opening into the vagina could not be identified. A tight, angulated, ulcerated stricture at the pouch inlet and another ulcerated stricture in the pre-pouch ileum were dilated up to 13.5 mm. Biopsies confirmed Crohn's disease of the pouch (CDP). The patient received infliximab with azathioprine with partial resolution of symptoms.

At 5 months, she had recurrent obstructive symptoms. Repeat TPUS revealed a persistent fistula and pouch thickening. Pouchoscopy showed a recurrent tight stricture at the pouch-anal anastomosis. Endoscopic stricturotomy was performed using an insulated-tip knife (IT knife, Olympus Medical Systems) with electrocautery settings Endocut-I 3–1-3 (VIO 300D, ERBE Elektromedizin GmbH, Tübingen, Germany) ([Fig. 1C]). Hybrid endoscopic stricturotomy and 18 mm balloon dilation were done for the long, ulcerated, angulated stricture at the pouch inlet ([Fig. 1D]) and the pre-pouch ileal ulcerated passable narrowing ([Video 1]). She was started on a low-residue diet, and obstructive symptoms improved significantly.

Herunterladen
Video 1 Preprocedure multimodality intestinal ultrasound (transabdominal, transperineal, and transrectal ultrasound)-guided hybrid endoscopic therapy (stricturotomy and balloon dilation).

Patient's Consent

Written informed consent was obtained from the patient for the publication of the information and imaging.




Publikationsverlauf

Artikel online veröffentlicht:
11. September 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Huguet M, Pereira B, Goutte M. et al. Systematic review with meta-analysis: anti-TNF therapy in refractory pouchitis and Crohn's disease-like complications of the pouch after ileal pouch-anal anastomosis following colectomy for ulcerative colitis. Inflamm Bowel Dis 2018; 24 (02) 261-268
    CrossrefPubMedSuche in Google Scholar
  • 2 Ardalan ZS, Friedman AB, Con D. et al. Accuracy of gastrointestinal ultrasound and calprotectin in the assessment of inflammation and its location in patients with an ileoanal pouch. J Crohns Colitis 2022; 16 (01) 79-90
    CrossrefPubMedSuche in Google Scholar
  • 3 Lan N, Wu JJ, Wu XR, L T, Hull, Shen B. Endoscopic treatment of pouch inlet and afferent limb strictures: stricturotomy vs. balloon dilation. Surg Endosc 2021; 35 (04) 1722-1733
    CrossrefPubMedSuche in Google Scholar
  • 4 Pal P, Nabi Z, Ramchandani M. et al. Endoscopic stricturotomy for inflammatory bowel disease strictures in anatomically challenging locations (deep small bowel, duodenum, anal canal and pouch): a case series with technical review (with videos). Indian J Gastroenterol 2025; 44 (04) 543-546
    CrossrefPubMedSuche in Google Scholar
  • 5 Pal P, Mateen MA, Gupta R, Tandan M, Reddy DN. Hybrid endoscopic stricturotomy and balloon dilation of ascending colon stricture with cecal fecaliths in Crohn's disease guided by preprocedural intestinal ultrasound. VideoGIE 2025
    Crossref