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CASE REPORT

Title: Use of endoluminal functional lumen imaging probe for the differential diagnosis of ileal pouch outlet obstruction

Author: Bo Shen, MD, AGAF, FACG, FASGE

Affiliation: Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA

Short title: Endoscopic imaging probe in ileal pouch

Correspondence:

Bo Shen, MD

Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center

Herbert Irving Pavilion-843

161 Ft Washington Ave

New York, NY, USA

Tel. 1 212 305 9664 FAX 1 212 305 0267

bs3270@cumc.columbia.edu

Disclosure of conflict of interest:

B.S.: Research/education grants: AbbVie, Boomrang, GIE Medical, Janssen, Sanofi, Takeda

Attestation:

The patients were identified from an Institutional Review Board-approved, prospectively maintained IBD database (AAAN3966). No part of the content of this manuscript has been published or considered to be published elsewhere. Consents for publication were obtained from the de-identified patients before endoscopy procedures.

ABSTRACT

Structural, inflammatory, and functional complications are common in patients with proctocolectomy and ileal pouch-anal anastomosis. Cross-sectional imaging, contrast pouchogram, pouchoscopy, and anopouch manometry are the main tools for the evaluation of these complications. Endoscopic luminal functional imaging, which has been used in assessing esophageal strictures and function, now finds its new application in the lower gastrointestinal tract. Here, two symptomatic patients with ileal pouch were evaluated with endoscopic luminal functional imaging, and the findings helped to direct proper medical therapy.

KEYWORDS

Diagnosis, Dyssynergia, Endoscopy, Ileal pouch, Stricture

ABBREVIATIONS

EndoFlip® or EFLI, endoluminal functional lumen imaging probe; IBD, inflammatory bowel disease; IPAA, ileal pouch-anal anastomosis; MAD, monitored anesthesia care; UC, ulcerative colitis

INTRODUCTION

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a preferred surgical treatment modality for patients with refractory ulcerative colitis (UC), colitis-associated neoplasia, or familial adenomatous polyposis. Since IPAA surgery preserves the natural route of defecation and avoids permanent ileostomy, it significantly improves patients' quality of life. However, this reconstructive surgery is often associated with various complications. The complications have been classified into 5 categories: 1) structural; 2) inflammatory; 3) functional; 4) neoplastic; and 5) systemic and metabolic adverse sequelae.[1] Pouch-anal anastomotic stricture and pelvic dyssynergic defecation are two primary phenotypes of structural and functional complications. Pouch strictures have been traditionally measured by cross-sectional imaging, contrast pouchogram, defecography, or pouchoscopy;[2] and pelvic dyssynergia is assessed with anopouch manometry.[3] The accuracy of the diagnostic modalities can be compromised by contractions and spasm of anal sphincters and adequate expertise of readers.

Endoluminal functional lumen imaging probe (EndoFlip® or EFLI) is an endoscopic device approved by the Food and Drug Administration for use in the measurement of esophageal stricture and motility. It can accurately measure lumen size of the esophagus with impedance planimetry. This author's group was the first to describe its use in the measurement of strictures in the lower gastrointestinal (GI) tract.[4],[5]The direct visualization of the size of the bowel lumen, length of stricture, and distensibility of EFLI before and after sedation or monitored anesthesia care can provide a valuable tool to measure the lumen and function of the lower GI tract. Here, two representative cases with dyssynergic defecation or mild anastomotic stricture were presented.

CASE REPORT

The first patient is a 34-year-old female who had restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) for medically refractory UC. Her past medical and surgical history also included anxiety, depression, post-traumatic stress disorder, obsessive-compulsive disorder, and appendectomy. She presented to our Pouch Center with persistent dyschezia, pelvic spasm, and even difficulty with self-catheterization through the anus. For her dyschezia symptoms, she was treated with anticholinergic agents, selective serotonin reuptake inhibitors, and Valium suppositories. Due to her persistent symptoms, she was referred to our Pouch Center. Anorectal manometry confirmed dyssynergic defecation or obstructive defecational disorder and a sawtooth contraction pattern. Pouchoscopy with EFLI was performed before and after monitored anesthesia care (MAC) with intravenous propofol (Figure 1). Before intravenous propofol was given, it was difficult to insert an esophagogastroduodenoscope due to severe anal spasm. EFLI showed a high-pressure zone, reflecting severe anal spasm. However, the high-pressure zone was relieved with intravenous propofol. Pouchoscopy showed normal mucosa of the prepouch ileum, pouch body, and anal transition zone and the absence of strictures or twist of the pouch. The patient's symptoms partially responded to pelvic biofeedback therapy and botulinum toxin injection of anal sphincters.

The 2nd patient is a 45-year-old female with total proctocolectomy and IPAA for refractory ulcerative colitis. Ever since IPAA, she has experienced frequent bowel movements, dyschezia, incomplete evacuation, and pelvic pain. Previous pouchoscopy evaluation showed normal mucosa of the pouch ileum, pouch body, and anal transition zone. The endoscopy also reviewed anastomotic strictures, which were empirically dilated with a mechanical balloon. However, her symptoms did not get any relief. Subsequently, barium defecography showed mild dyssynergia. Anopouch manometry showed high resting and squeeze pressures and failed balloon expulsion tests. Pouchoscopy and EELI were performed before and after MAC. FFLI showed a similar luminal size of the anastomosis before and after MAC, suggesting a limited impact of voluntary contraction of the anal sphincters on the diameter of the anastomosis (Figure 2). Normal pouchoscopy along with normal EFLI findings pre- and post- sedation suggests a diagnosis of irritable pouch syndrome. Her symptoms responded favorably to an oral selective serotonin reuptake inhibitor.

DISCUSSION

Clinical presentations of structural, inflammatory, and functional complications of IPAA often overlap. For example, patients with strictures at the pouch-anal anastomosis or dyssynergia can all present with dyschezia, anal spasm, pelvic pain, incomplete evacuation, bowel frequency, excessive straining, and excoriation of perianal skin. Those two conditions may coexist, amking differential diagnosis difficult. These complications have been traditionally evaluated with abdominal imaging, pouchoscopy, and anopouch manometry.

EFLI provided a new dimension for the diagnosis and differential diagnosis. We previously reported the use of EFLI in the diagnosis of lower GI tract stricture and the assessment of response to endoscopic treatment of strictures.4,5 The current study illustrated the use of the EFLI techniques to assess the anal sphincter function and impact of voluntary contractions on the patency of pouch-anal anastomosis. The colored illustration of EFLI imaging is easy to read and comprehend.

There are limitations to the use of EFLI in the lower GI tract. The catheter was only inserted along, not through, the endoscope, making EFLI measurement of the right side of the lower GI tract infeasible. ELIP does not directly detect sensation of the bowel. Therefore, the diagnosis of irritable pouch syndrome was made by exclusion.

In summary, this is the first report using endoscopic luminal functional imaging for the assessment of structural and functional disorders of the ileal pouch. The findings helped to direct proper medical therapy.

FIGURE LEGENDS

Figure 1. Pouchoscopy and endoscopic functional luminal imaging of patients with severe anal spasm. The function and lumen of the anal sphincters significantly changed before and after sedative medications

Figure 2. Pouchoscopy and endoscopic functional luminal imaging of patients showed normal anal sphincter and anastomosis. The function and lumen of the anal sphincters did not significantly change before and after sedative medications

REFERENCES (NLM Format)

[1] Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol. 2021 Oct;6(10):826-849. doi: 10.1016/S2468-1253(21)00101-1. Epub 2021 Aug 18. PMID: 34416186.

[2] 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 Apr;35(4):1722-1733. doi: 10.1007/s00464-020-07562-z. Epub 2020 Apr 18. PMID: 32306110.

[3] Khanna R, Li Y, Schroeder T, Brzezinski A, Lashner BA, Kiran RP, Remzi RH, Shen B. Manometric evaluation of evacuatory difficulty (dyschezia) in ileal pouch patients. Inflamm Bowel Dis. 2013 Mar;19(3):569-75. doi: 10.1097/MIB.0b013e31827e78d6. PMID: 23380934.

[4] Choy AM, Pomenti S, Katzka DA, Shen B. Novel Use of EndoFLIP to Characterize Kock Pouch Stricture Before and After Endoscopic Intervention. ACG Case Rep J. 2024 Nov 20;11(11):e01555. doi: 10.14309/crj.0000000000001555. PMID: 39568981; PMCID: PMC11578196.

[5] Pomenti S, Katzka DA, Shen B. Application of functional lumen imaging probe in the evaluation and treatment of anorectal strictures. Gastrointest Endosc. 2025 Feb;101(2):477-479. doi: 10.1016/j.gie.2024.09.003. Epub 2024 Sep 17. PMID: 39265748.