J Pouch: Imaging Findings, Surgical Variations, Natural History, and Common Complications.

Ileal pouch-anal anastomosis, or J pouch, surgery has become the procedure of choice for treatment of medically refractory ulcerative colitis and familial adenomatous polyposis. Overall, this operation is associated with a low rate of postoperative morbidity and good long-term function. However, when complications develop, there is a heavy reliance on imaging to facilitate an accurate diagnosis. Reported postoperative complication rates range from 5% to 35%. Complications generally can be categorized as structural, inflammatory, or neoplastic conditions. Structural complications include leaks, strictures, afferent and efferent limb syndromes, and pouch prolapse. Inflammatory conditions include cuffitis, pouchitis, and Crohn disease of the pouch. In addition, a variety of neoplastic conditions can develop in the pouch. Overall, pouchitis and leaks are the most common complications, occurring in up to 50% and 20% of individuals, respectively. Many imaging modalities are used to evaluate the J pouch and associated postoperative complications. The indications and various surgical techniques for J pouch surgery, normal postoperative appearance of the pouch, and most common associated complications are reviewed. In addition, the various imaging findings associated with J pouch surgery are described and illustrated. The radiologist's familiarity with the potential complications of the pouch can facilitate appropriate imaging, hasten an accurate diagnosis, and aid in rendering proper management. ©RSNA, 2018.

Voriconazole-induced periostitis: beyond post-transplant patients.

Voriconazole-induced periostitis (VIP) is a rare but increasingly encountered entity since Food and Drug Administration (FDA) approval of the second generation antifungal medication in 2002. Literature reports most commonly include transplant recipients on immunosuppressive therapy simultaneously requiring antifungal therapy. Nontransplant patients receiving long-term voriconazole have an equal risk of developing the disease, but may experience a delay in diagnosis due to a lack of familiarity with the process outside of the post-transplant and/or immunosuppressed population. We present a case of VIP in a nontransplant, immunocompetent patient on suppressive antifungal therapy for prior abdominal aortic stent graft fungal infection. Radiologist review of current medications and recognition of periostitis on multiple imaging modalities may hasten the diagnosis and lead to earlier treatment and resolution of symptoms.

Judging the J pouch: a pictorial review.

Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.