Clinical Features and Management of Postoperative Pouch Bleeding after Ileal Pouch-Anal Anastomosis (IPAA)

Aim The clinical features of postoperative bleeding from the ileal pouch-anal anastomosis(IPAA) vary and its management can be difficult. There is no published literature regarding pouch bleeding and its treatment. Materials and Methods Pouch bleeding was defined as the passage of blood or clots transanally or into the ileostomy bag with or without hypotension or a drop in hemoglobin within 30 days after surgery. Patients were identified from a prospectively maintained pouch database. Results Pouch bleeding developed in 47 (1.5%) patients out of 3,194 patients undergoing IPAA since 1983. Forty-two patients had inflammatory bowel disease, four had familial adenomatous polyposis, and one had colonic inertia. Sixty-six percent of bleeding occurred within 7 days postoperatively and 59.6% required transfusion; 72.3% patients developed transanal bleeding, nine from ileostomy and two from both. After initial fluid resuscitation, five patients were observed while 28 patients had pouch endoscopy and clot evacuation followed by cauterization or epinephrine(1:100,000) enemas, 27 of these had cessation within 24 h. Epinephrine enema was used as initial treatment in the remaining 12 patients. Overall success rate of epinephrine enema was 96%. Conclusion Postoperative pouch bleeding after IPAA is uncommon, and it usually requires nonsurgical intervention. Epinephrine enema appears to be successful in managing this complication.