title: Is it really small-bowel obstruction in patients with paradox after IPAA?
abstract: BACKGROUND
  Diagnosing outlet obstruction after IPAA can be challenging because the etiology is multifactorial.
  
  
  OBJECTIVE
  The aim of this study was to assess possible factors associated with outlet obstruction from paradoxical anal muscle contraction (paradox) after IPAA unrelated to strictures or structural abnormalities.
  
  
  METHODS
  This was a retrospective study from a prospectively maintained pouch database.
  
  
  METHODS
  The study was conducted at a tertiary referral center.
  
  
  METHODS
  All of the patients with paradox after ileal J-pouch-anal anastomosis verified by anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic abnormalities were excluded.
  
  
  METHODS
  Demographic, clinical, and perioperative factors were obtained, including previous abdominal operations, history of pouchitis, need for anal intubation, diagnosis of small-bowel obstruction, and radiologic findings at the time of paradox diagnosis.
  
  
  RESULTS
  There were 40 patients (17 women) with an overall mean age of 39 years (range, 17-60 years) and a mean follow-up of 15 years (range, 1-28 years) after IPAA. Pathologic diagnoses at the time of ileal pouch creation were ulcerative colitis (n = 27), indeterminate colitis (n = 11), Crohn's disease, and familial adenomatous polyposis (1 case each). A total of 15 (37%) of 40 patients were diagnosed with small-bowel obstruction before their paradox diagnosis, 8 of whom underwent surgery, which revealed diffusely dilated small bowel and pouch without intraoperative identification of a transition point. The time from ileal pouch creation to paradox diagnosis was significantly longer in patients receiving a diagnosis of small-bowel obstruction than in the remaining paradox patients (7.2 vs 2.6 years; p < 0.001).
  
  
  CONCLUSIONS
  This study was limited by its nonrandomized retrospective nature.
  
  
  CONCLUSIONS
  After an IPAA, patients with outlet obstruction from paradox can appear to have a small-bowel obstruction. A high incidence of suspicion is needed to make the correct diagnosis and avoid an unneeded laparotomy.
authors: Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.
authors: Jorge
authors: J
authors: Silva-Velazco
authors: Tracy L
authors: TL
authors: Hull
authors: Luca
authors: L
authors: Stocchi
authors: Emre
authors: E
authors: Gorgun
mesh_terms: D011125:Adenomatous Polyposis Coli / Q000601:surgery*; D000328:Adult; D001003:Anal Canal / Q000473:pathology / Q000503:physiopathology; D039021:Colonic Pouches / Q000009:adverse effects*; D003951:Diagnostic Errors / Q000517:prevention & control*; D005260:Female; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000601:surgery*; D007415:Intestinal Obstruction / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction; D009820:Ohio; D011183:Postoperative Complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D016737:Proctocolectomy, Restorative / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D016896:Treatment Outcome