Untwisting the plot: Resolving a misdiagnosis of Crohn's disease in an ulcerative colitis patient with a twisted J-pouch-A video vignette.

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) are two primary forms of inflammatory bowel disease, both characterized by chronic, relapsing inflammation of the gastrointestinal tract. Clinicians differentiate between CD and UC using a combination of clinical, endoscopic and histological findings. However, there are instances where the initial pathology is indeterminate, or a diagnosis of CD or UC may change over time. Patients with UC are often considered candidates for proctectomy with ileal pouch-anal anastomosis (IPAA). Despite this, UC patients undergoing IPAA are still at risk of pouch failure. Additionally, pouch twisting can mimic symptoms of CD, further complicating the diagnosis. In such cases, detailed clinical examination and advanced imaging are essential for accurate diagnosis. This video presents a case of a UC patient who initially underwent proctocolectomy with IPAA and was later treated for what was believed to be misdiagnosed CD, which was, in fact, a twisted pouch requiring a redo IPAA.

INTERVENTION

We present the case of a 48-year-old woman with a history of UC who underwent a robotic total proctocolectomy with ileoanal J-pouch creation followed by diverting loop ileostomy closure in 2019. The patient later experienced abdominal pain, an inability to empty the J-pouch, and food avoidance shortly after the operation, initially suspected to be due to misdiagnosed CD and pouch failure. Various treatments, including biological and immunosuppressive treatments, were used in the patient's treatment. In January 2023, the patient underwent ileostomy creation and was referred to our centre. Flexible sigmoidoscopy and pouchography revealed mucosal congestion consistent with chronic ischaemia and a partial obstruction in the prepouch ileum. During laparotomy, a twisted pouch in the efferent limb was confirmed. Additionally, severe fibrosis was noted in the existing J-pouch, extending from the rectal cuff downward around the vagina, suggestive of either chronic subclinical leakage or pouch dysfunction associated with an elongated anterior rectal cuff. Based on these findings, we proceeded with pouch excision and redo J-pouch reconstruction with diverting loop ileostomy. The procedural details are described in Video 1.

OUTCOME

The surgical procedure was completed in 316 min with an estimated blood loss of 150 mL. No intraoperative complications were observed. The patient was discharged without postoperative complications. The diverting loop ileostomy was successfully reversed after 3 months. At follow-up, the patient had gained 10 kg and was tolerating a regular diet. No biological therapy was initiated.

CONCLUSION

This case highlights the critical importance of thorough diagnostic evaluation in patients with suspected pouch complications. Misdiagnosis can lead to unnecessary and ineffective interventions. Timely recognition and correction of the twisted pouch is crucial to improve symptoms and overall outcome in patients with twisted pouch.