Hemorrhagic pouchitis after bowel preparation with sodium phosphate-based enema: a case report

Proper bowel preparation is crucial for endoscopic evaluation and intervention of the ileal pouch; yet, evidence on optimal regimens remains unclear. Although guidelines recommend the polyethylene glycol (PEG) regimens in patients with inflammatory bowel disease, sodium phosphate-based (NaP) enemas often are used for convenience. Although oral NaP has been linked to mucosal injury, similar effects from enemas have not been documented, to our knowledge. We report a case of hemorrhagic pouchitis after an NaP enema use in a patient with Crohn's disease of the pouch who required repeated endoscopic stricturotomy. Endoscopic hemostatic agents were applied and stricture therapy was deferred to avoid further injury. No other prohemorrhagic causes besides NaP enema were identified. One month later, repeat pouchoscopy using PEG preparation showed no signs of active or recent bleeding, and endoscopic stricturotomy was successfully delivered. NaP enema should be used with caution in patients with an ileal pouch, as they can induce mucosal injury or mimic worsening pouchitis, potentially leading to misdiagnosis and inappropriate management.