Aim: The clinical features of postoperative pouch bleeding vary and the management can be difficult. There is no published literature regarding pouch bleeding and its treatment.
Methods: Pouch bleeding was defined as significant bleeding or passing of clots transanally or into loop ileostomy bag with/without hypotension or drop in hemoglobin within 30 days after surgery. Patients were identified from a prospectively maintained Pouch Database.
Results: Pouch bleeding developed in 47(1.5%) patients out of 3194 patients undergoing IPAA since 1983. 42 had inflammatory bowel disease, 4 had familial adenomatous polyposis, and 1 had colonic inertia. Staple line reinforcement was used in 17(44.7%) patients with J pouch. 66% bleeding occurred within 7 days, of who 41.9% had postoperative anticoagulant use for thrombosis prophylaxis. 34(72.3%) bled from neo-rectum, 9 from ileostomy, 2 from both. 2 patients had concurrent abdominal bleeding and 2 had anemic symptoms who were later found bleed from pouch by endoscopy. After initial fluid resuscitation, 28 patients had pouch endoscopy and clot evacuation followed by cauterization or iced saline and saline with epinephrine (1:100000) enemas. 27 of 28 had cessation of bleeding within 24 hours. 1 patient required 3 days of enema treatment before complete cessation. Epinephrine enema was used as initial treatment in 12 patients. 1 patient failed and had endoscopy with cauterization of bleeding point. 5 patients were observed. 28 patients were transfused. No surgery was required for pouch bleeding.1 patient had reoperation and 1 patient died after transferred to intensive care unit due to concurrent intra-abdominal bleeding.
Conclusion: Postoperative pouch bleeding after IPAA usually required intervention and can be managed nonoperatively. Pouch endoscopy with clot evacuation and cauterization of visible bleeding point followed by iced saline and saline with epinephrine enema is successful in managing this complication.
Table 1.Comparison:Patients with and without Pouch Bleeding.

	Pouch Bleeding (N=47)	No Pouch Bleeding (N=3147)	P Value
Age	33.3+/-10.5	47.3+/-13.8	0.011
Gender=male	34(72.3%)	1752 (55.5%)	0.106
Pouch type= J(vs. S)	38(80.9%)	2764(87.8%)	0.148
Anastomotic type=Stapled(vs. Hand-sewn)	35(74.5%)	2618(83.2%)	0.114

Table 2.Management of Pouch Bleeding and Outcomes

Initial Treatment:Endoscopy and Clot Evacuation(No.=28,59.6%)
Followed by Cauterization (Active Bleeding)	15(53.6%)
Followed by Epinephrine Enema (No Distinct Bleeding)	13(46.4%)
Initial Treatment:Epinephrine Enema(No.=12,25.5%)
Success	11(91.7%)
Need Endoscopy and Cauterization	1(8.3%)
Observation with/without Transfusion	5