Pouchogram
This procedure is done on patients who have had a total colectomy with an Ileo-Anal Reservoir anastomosed at the anal verge. This procedure is done mostly for patients with ulcerative colitis, colonic polyposis and sometimes for colonic cancers.

The pouchogram is done to assess for leaks or other long term complications such as strictures at the ileo-anal anastomosis or the pouch itself; sometimes to assess the capacity of the pouch.

Most leaks occur in the immediate post-operative period and are located at the ileo-anal anastomosis especially the posterior aspect; therefore during fluoroscopy the patient should be first n a lateral position to assess the pouch. Then one can fluoroscope in an oblique and AP position to check for leaks at the lateral aspect of the anastomosis.
 

Equipment

  • 12F Foley catheter
     
  • Xylocaine gel
     
  • Toomey Syringe
     
  • Clamp
     
  • Contrast:
    • Hypaque 30% (unless otherwise stated)


Technique

The study can be performed through an existing rectal tube or one can inset a small (12 F) Foley catheter into the pouch. DO NOT INFLATE THE BALLOON. The Foley catheter balloon is not inflated so that leaks at the ileo-anal anastomosis are not obscured. Sometimes the surgeon may ask to check the pouch via the DISTAL LOOP ILEOSTOMY opening. It is best to confirm the route of the examination with the surgeon.

The contrast used is almost always HYPAQUE 30% concentration.


Radiographs

Scout film, lateral, L.A.O., R.A.O. and AP views with contrast.

In patients who have been operated on more than 4 weeks, one should do a STRAINING view in AP and lateral projections. Please split films to minimize film usage.

A POST-EVACUATION view is also done in some patients who are being assessed for pouch integrity and ileostomy closure. Both AP and lateral views are done on a single 8x10 radiograph split.

Barium (30% w/v) may be used for patients being assessed for long-term complications.

LATERAL SCOUT VIEW:

Both AP and lateral scout radiographs are done. These views will assess the amount of air in or behind the pouch or in the vagina (in case of an ano-vaginal fistula). This view will localize the bowel sutures which can mimic a leak after contrast has been instilled into the pouch.

All images are taken on 9" FOV.
 		 POUCHOGRAM:

The pouch is filled with small quantities of contrast and checked fluoroscopically for any leaks. Images are taken mostly in the lateral position where leaks are best detected (either posterior or anterior at the ano-pouch junction – arrow).
OBLIQUE VIEW:

This view ensures that there are no subtle postero-lateral leaks. The anal canal must be opacified on ALL views to ensure proper and complete evaluation of the ileo-anal anastomosis.		 AP VIEW:

This will ensure detection of possible antero-lateral leaks.  If the anal canal cannot be opacified on any views, ask the patient to perform a Valsalva maneuver.  This will serve two purposes: to fill the anal canal and to show any small leaks.
 
AP. VIEW:

Taken with 12” FOV to show the entire pouch and the ileostomy opening.		 LATERAL VIEW:

Taken with 12” FOV to show the entire pouch and the ileostomy opening.
 
POST EVACUATION VIEW:

The catheter is removed and the patient is asked to evacuate the pouch contents. This is to assess the post evacuation residue and sometimes a leak occurs after the forced evacuation of the contrast.		 POST EVACUATION VIEW:

Both AP and Lateral views are taken.  Most leaks occur at the posterior aspect of ileo-anal pouch anastomosis. Other sites include anterior, lateral anastomosis and at the blind ended ‘afferent limb’. Rarely, the leak can occur at the midline suture line of the pouch. There may also be an ano-vaginal fistula