Male patient, 48 years old, with severe universal ulcerative colitis. Symptoms began
in 1994. Due to clinical intractability, the patient underwent total proctocolectomy
with ileal pouch and loop ileostomy in 2007, with closure of the ileostomy in the
same year. In 2009, the patient developed anal stenosis and underwent surgical dilation.
In the same year, he had an episode of subocclusion and underwent exploratory laparotomy
for adhesiolysis. In 2017, the patient developed a perianal fistula but refused surgical
treatment. Biologic therapy with Adalimumab was started. In 2021, intestinal transit
showed a normal-appearing ileal pouch. In 2023, the patient reported mild abdominal
distension and a sensation of fullness, with an average of 2 bowel movements per day.
An enteric MRI was performed, showing an increase in the ileal pouch with proximal
dilation, without any obstructive factors. The patient developed a symptomatic incisional
hernia. During the intraoperative procedure, prolapsed dilated small bowel loops were
identified. The ileal pouch was large (40 × 20 cm), with proximal dilation and no
points of obstruction. The intraoperative proctological examination showed adequately
patent pouch-anal anastomosis. As no obstruction points were identified, only the
pouch was emptied, and the incisional hernia was corrected. No justification for the
late pathological dilation of the ileal pouch was found. There was no relation to
the anal pouch-anastomosis stenosis, as it occurred 15 years earlier and was resolved.
The imaging exam in 2021 showed a normal pouch. In 2023, the patient presented frustrating
symptoms, leading to an imaging exam that already demonstrated pouch dilation, and
due to improvement with symptomatic treatment, no intervention was made. It was not
possible to diagnose what caused the dilation, and there was no consensus on the approach,
as despite the dilation, the patient remained oligossymptomatic. Over the years, during
the late follow-up of patients with ileal pouches, more frequent complications such
as pouchitis and less frequent ones such as total ileal pouch prolapse, fecaloma with
the need for emptying, and now identified pathological dilation of the pouch, have
been recognized. No reports of ileal pouch dilation without obstructive factors were
found in the literature. Even after years of satisfactory evolution in these patients,
attention must be given to these rare and late complications.
