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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.

Over the last several years there has been an increasing interest and utilization of cross-sectional imaging techniques for evaluation of the bowel in inflammatory bowel disease (IBD), especially for Crohn’s disease. Cross-sectional imaging can evaluate the entire gastrointestinal tract, depict transmural and perienteric inflammation, detect complications such as fistulas and abscesses—which may be not be evident with techniques used to evaluate the mucosal surface—and assess other abdominal organs and structures. Both computed tomography (CT) and magnetic resonance (MR) have advantages and limitations, which must be understood to perform the most appropriate imaging test in any given clinical scenario. Barium fluoroscopic exams still maintain some advantages over the cross-sectional techniques, such as higher spatial resolution and the ability to examine bowel peristalsis and distension in real time. In this article we explain the clinical benefits and appropriate utilization of cross-sectional enterography, review the technique and performance of CT enterography (CTE) and MR enterography (MRE), and discuss the findings and approaches to interpretation. Finally, we highlight the advantages and role of fluoroscopic examinations.