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AIM: Distal small bowel obstruction following ileal pouch-anal anastomosis (IPAA) can be caused by afferent limb syndrome due to acute angulation or prolapse of the afferent limb at the pouch inlet. The aim of this study is to report our experience regarding presentation and management of afferent limb syndrome in patients with IPAA.METHODS: All patients who had afferent limb syndrome after IPAA and were treated at the Cleveland Clinic were identified from prospectively maintained pouch and Pouchitis Clinic Databases. Data including demographics, details of IPAA, symptoms due to obstruction, radiologic and endoscopic investigations, endoscopic and surgical procedures performed for afferent limb syndrome, and outcomes after these treatments was collected. This study was approved by Institutional Review Board.RESULTS: There were a total of 14 ulcerative colitis patients with afferent limb syndrome after IPAA. Nine were female. Median age was 34.5 (range, 16-60) years at the time of IPAA. Eight patients had primary IPAA elsewhere. Patients presented with intermittent obstructive symptoms including chronic abdominal pain (n=12), bloating (n=3), constipation (n=2) and perianal pain (n=1). Some patients had more than one symptom. In all patients, angulation of pouch inlet and difficulty in intubating the afferent limb was detected at pouchoscopy. In 8 patients kinking or narrowing of the pouch inlet were identified using gastrograffin enema (n=6), defecography (n=1) or small bowel series (n=1). Of 14 patients, 7 had successful balloon dilatation of the afferent limb without the need for surgery. One patient has been scheduled for surgery due to failure after dilatation. Four patients without dilatation had surgery including resection of angulated bowel (n=2) or pouch excision with end ileostomy (n=2). In 1 patient, symptoms due to afferent limb syndrome relieved after conservative management. The last patient was lost to follow-up. CONCLUSION: A combined assessment of endoscopy and abdominal imaging is important to establish the diagnosis of afferent limb syndrome. Endoscopic or surgical intervention is often needed.