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INTRODUCTION: Approximately 30% of ulcerative colitis (UC) patients require surgery during their disease course. Patients will commonly undergo total proctocolectomies with subsequent creation of a “pouch,” such as a J-pouch (pelvic pouch with ileal pouch-anal anastomosis) or a Kock pouch. A small portion of patients undergoing “pouch” procedures for UC will develop severe symptoms related to the inflow limb of the pouch requiring operative intervention. A clear understanding has not been established as to the pathological mechanism by which these pouch inflow problems develop and what pathologic entity they belong. METHODS: Methods: A retrospective chart review was conducted at a single tertiary medical center. A database was created of all patients who underwent subsequent pouch-related surgical procedures between 2006 and 2018. Patients with requiring operative intervention of the inflow limb were identified among this cohort. Operative and pathological data were collected. RESULTS: 178 patients were identified who underwent procedures yielding a surgical pathologic specimen related to their pouch. 15 of these procedures reported significant pathology of the inflow limb to the original pouch (9 J-pouches and 6 Kock pouches), occurring on average of 19.6 years after the creation of the original pouch. The most common diagnosis requiring reoperation was obstruction due to stricture formation (n = 11). Reoperations for inflow limb pathology included pouch excision (n = 3), inflow limb resection with ileo-pouch anastomosis (n = 9), stricturoplasty (n = 1), and bypass of the inflow limb (n = 1). In addition, 3 patients required a temporary, diverting loop ileostomy as part of their reoperation. The pathologic findings of the inflow limb were consistent with Crohn's ileitis in 6 patients (40%). 3 other patients (20%) were diagnosed with Crohn's disease and had diagnostic findings suspicious of Crohn's on inflow limb pathology. Remaining patients (n = 6) were found to have chronic, nonspecific enteritis/serositis. There was one case of poorly differentiated adenocarcinoma. CONCLUSION: A small proportion of patients who have undergone a “pouch” procedure require eventual surgery for a problem with the inflow limb of the pouch. These patients were found to have a high rate of Crohn's disease of the inflow limb and overall change in diagnosis to Crohn's disease.