Ileo-Anal Reservoir (J-Pouch) Complications
Are there any complications that can happen with an Ileo-anal reservoir (IAR) operation?
There are possible complications that are associated with any abdominal operation. There are also possible complications that are more specific to the IAR operation. Whether a complication occurs or not may depend on certain things like your overall health status prior to the operation, medication use (steroids), and nutrition. Your health care team will not be able to predict if you will or will not have a complication, but the team will provide you with care that may help to prevent these from occurring. Some of the complications which may occur after an abdominal operation include:
- an obstruction in the bowel, preventing fluids/solids from passing through
- a delay in the return of normal bowel function (paralytic ileus)
- an infection to the incision and underlying tissues, sometimes causing an open wound, or a deeper collection of infected fluid in the abdomen (abscess)
- a blood clot in the lower leg (thrombosis) which can travel to the lung (pulmonary embolus)
- a urinary tract infection
- collapse of lung tissue (atelectasis) or infection (pneumonia) in the lungs.
Your surgeon will be able to discuss these with you before the operation. Complications that are more specific to the IAR procedure can be divided into two types: short-term (soon after surgery) and long-term (happening months or years after surgery). You should discuss these complications with your surgeon. While no-one can predict if you will or will not have a complication, you can be told how often these complications tend to occur in people who have the IAR procedure.
- a loss of too much fluid and electrolytes (dehydration) may initially occur with the temporary loop ileostomy
- a leak at the connection of the new reservoir to the anus, causing a pelvic abscess (a collection of infected fluid) or infection in the abdomen (peritonitis)
- sexual dysfunction (for women, painful intercourse or vaginal dryness; for men, problems with erection or ejaculation, or impotence)
- an inflammation of the reservoir causing diarrhea, cramps, bloating (pouchitis)
- a narrowing of the connection between the reservoir and the anus (stricture), making it difficult to empty the reservoir
- leakage of the stool from the reservoir, either at night or during the day (incontinence)
- diarrhea or ongoing frequent bowel movements
- Crohn’s disease (some patients, especially those with indeterminate colitis may turn out to have Crohn’s disease which can affect the anus, the reservoir, other parts of the gastrointestinal tract)
Can these long-term complications be treated?
- Pouchitis: Pouchitis is an inflammation of the reservoir (or pouch) causing diarrhea, cramps and bloating. Pouchitis tends to occur only in patients who have the IAR for ulcerative colitis or indeterminate colitis. The chance of developing pouchitis at some point depends upon how long you have had your reservoir. The longer you have your reservoir, the more likely you are to develop an episode of pouchitis. After 10 years, the chance of having an episode of pouchitis may be as high as 50%. The cause of pouchitis is not known. Pouchitis is usually treated with antibiotics. The most commonly used antibiotics are metronidazole (Flagyl™) and ciprofloxacin. Usually, after 7-10 days of oral antibiotics, the symptoms of pouchitis will be gone. If you suspect that you are having pouchitis, then contact your surgeon to discuss your concerns.
- Stricture: A stricture is a narrowing at the connection between the reservoir and the anus. The narrowing is caused by scar tissue. If a stricture is developing, you will notice that it is more difficult to empty the reservoir: it takes longer and you must use more force (or bear down more) in order to empty the reservoir. If you notice these symptoms, then contact your surgeon. The narrowing can be stretched (or dilated) to open the connection.
- Incontinence: Uncontrolled leakage of stool from the reservoir can occur. Most often, leakage occurs at night when you are sleeping and the anal sphincters are relaxed. Some medications, like sleeping pills, may contribute to the incontinence. You may find that wearing a small pad in your underwear is enough to help manage the leakage of stool.
Leakage may also occur during the day. You may find that thickening the stool with certain foods or medications may help to decrease the leakage (pasty or semi-formed stool is easier to “hold on to” than liquid stool). You may also want to try and strengthen your pelvic muscles with Kegel exercises. You can discuss diet changes with your dietitian and Kegel exercises with your Enterostomal Therapy Nurse.
- Diarrhea: Ongoing loose stools (more than 8 per day) may occur in some patients with the IAR. Initially, dietary changes are made to try to control the looser stools. Your dietitian can help you with these changes. Try to remove foods and drinks from your diet that may cause looser stools. Try to add foods that will thicken stools. If dietary changes don’t work, you may need to use some medications to help control the diarrhea such as Imodium™ or Lomotil™. If you are having ongoing problems with loose stool, contact your Enterostomal Therapy Nurse or surgeon to discuss further management.
Will I still have a risk of cancer after I have the IAR?
The risk of developing cancer in the reservoir or the anus is extremely low. However, you should still have regular surveillance of your reservoir and anus on a regular basis to monitor any changes. This is usually done once a year. Your surgeon will discuss with you how often you should return for inspection of your reservoir.
Does the IAR have any impact on fertility and childbirth?
Any abdominal surgery can potentially have an impact on a woman’s fertility, either due to the surgery itself (scar tissue formation, or adhesions) or due to possible complications from the surgery (infections or abscesses in the abdomen). The overall risk is low, and your surgeon can discuss this with you. Having an IAR is not a contraindication to pregnancy.
During pregnancy, some women may find that reservoir function during the first trimester will increase as the enlarging uterus “competes” for space in the pelvis. The reservoir may not be able to fully expand with a “normal” amount of stool. This usually resolves during the second and third trimesters, as the uterus moves out of the pelvis and the reservoir can once again expand normally.
The risks and benefits of a vaginal delivery versus a caesarean section and the impact of each on your IAR should be discussed with your surgeon and obstetrician.
Are there any resources in the community for people with an IAR?
There are many resources available for people with ileo-anal reservoirs. Your Enterostomal Therapy Nurse can give you a list of web sites, booklets and support groups for people undergoing this surgery.