Characterization of risk factors for floppy pouch complex in ulcerative colitis

  • Khan Freeha
  • Xian Hua Gao
  • Tracy L. Hull
  • Bo ShenEmail author
Original Article



Restorative proctocolectomy with ileal pouch–anal anastomosis can be associated with a variety of complications, including floppy pouch complex (FPC). FPC is defined as the presence of pouch prolapse, afferent limb syndrome, enterocele, redundant loop, and folding pouch on pouchoscopy or contrasted pouchogram. The main symptoms of patients with FPC are dyschezia, incomplete evacuation, and bloating. The aims of the study were to evaluate the relative frequency of each disorder of FPC and to characterize its risk factors.


This case–control study included all eligible patients with FPC from our prospectively maintained, IRB-approved Pouchitis Registry from 2011 to 2017. The control group included the patients without any of the above conditions. Univariate and multivariate analyses were performed.


A total of 437 eligible patients were analyzed including 97 (22.2%) with FPC and 340 (77.8%) without FPC, 188 (43.0%) being female, 360 (82.4%) being Caucasians, and 66 (15.1%) having a family history of inflammatory bowel disease (IBD). There were 427 patients (97.7%) having J pouches and 10 (2.2%) having S pouches and the median duration from pouch construction to data sensor was 6.0 years (interquartile range 0.962–1.020). In the whole cohort, 64 (66.0%) patients had pouch prolapse, 38 (39.2%) patients had afferent limb syndrome, 10/42 (23.8%) patients had redundant loop, and 3/42 (7.1%) had folding pouch. In multivariable analysis, lower body weight (odds ratio [OR] 0.944; interquartile range; 95% confidence interval [CI] 0.913–0.976, P = 0.001) and the presence of family history of IBD (OR 4.098; 95% CI 1.301–12.905, P = 0.013) were associated with a higher risk of FPC.


We found that pouch prolapse and afferent limb syndrome are the most common forms of FPC. A lower body weight as well as family history of IBD was found to be risk factors for FPC. The findings will have implications in both diagnosis and investigation of etiopathogenesis of this group of challenging disorders.


Afferent limb syndrome Body mass index Dyschezia Enterocoele Floppy pouch complex Gender Ileal pouch–anal anastomosis Pouch Prolapse Ulcerative colitis 



Dr. Bo Shen holds the Ed and Joey Story Endowed Chair.

Author contribution

Freeha Khan and Xian Hua Gao contributed equally to this article.

Freeha Khan and Xian Hua Gao: Data gathering and entry, imaging measurement, and manuscript preparation.

Bo Shen and Tracy Hull: Concept, general supervision, and manuscript revisions.

Compliance with ethical standards

The Institutional Review Board (IRB) of the Cleveland Clinic Foundation approved this study.

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Khan Freeha
    • 1
  • Xian Hua Gao
    • 2
  • Tracy L. Hull
    • 2
  • Bo Shen
    • 1
    Email author
  1. 1.Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute-A31The Cleveland Clinic FoundationClevelandUSA
  2. 2.Department of Colorectal Surgery, Digestive Disease and Surgical InstituteCleveland ClinicClevelandUSA

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