Iron-deficiency anemia as presentation of pouchitis

GOALS

This study sought to describe the percentage and cause of anemia in patients who underwent ileal pouch with anal anastomosis (IPAA) for ulcerative colitis (UC), and to compare the distribution of complications in patients with and without anemia, especially pouchitis, after IPAA.

BACKGROUND

IPAA is the surgical procedure of choice for UC. Complications include pouchitis (40%), strictures (30%), small bowel obstruction (10%), pelvic sepsis (<5%), and urinary and sexual dysfunctions (<5%). Few studies have described the prevalence of anemia after IPAA, but no conclusive findings have been reported.

STUDY

Patients who had undergone IPAA for UC were recruited from the UPR Inflammatory Bowel Disease Clinic and the Gastroenterology Research Unit. Demographic and medical data were obtained. Anemia was diagnosed using standard hematologic criteria. Serum iron, ferritin, transferrin, folate, vitamin B12, erythropoietin, total iron-binding capacity, reticulocyte count, peripheral smear, and bone marrow aspirate were evaluated in patients with anemia. Data analysis was performed with EPI Info version 6.4d.

RESULTS

Iron-deficiency anemia was identified in 55.5% (10/18) of patients and pouchitis was found in 77% (14/18). All 10 patients with anemia had pouchitis, whereas only 4 of the 8 without anemia had pouchitis. In half of the anemic patients, pouchitis was asymptomatic.

CONCLUSIONS

Iron-deficiency anemia may be a clinical presenting sign of pouchitis. Hemoglobin levels may be considered as surveillance tools for pouchitis in patients with IPAA.

Dysbiosis and pouchitis

BACKGROUND AND METHODS

The exact aetiology of pouchitis is unknown, but an association with dysbiosis has been suggested. This is a retrospective review of 17 studies published between 1985 and 2005, identified by a search of the Medline, Pubmed and Embase databases.

RESULTS

The methodology of the studies varied widely. Many were performed at a time when the distinction between a healthy and an inflamed pouch was vague; misclassification of patients makes the analysis of data difficult and conclusions uncertain.

CONCLUSION

The evidence that dysbiosis is a cause of pouchitis is poor. Nevertheless, available data allow the construction of an algorithm to aid management and suggest a structured approach for future research.

MRI of complicated pouchitis

OBJECTIVE

The purpose of this study is to assess the ability of MRI to identify the presence of inflammation related to the pouch reservoir in symptomatic patients with an ileal pouch-anal anastomosis who present with clinically suspected complicated pouchitis.

CONCLUSION

Initial results suggest that MRI should be considered in patients who have undergone ileal pouch-anal anastomosis and present a clinical impression of complicated pouchitis. MRI showed abnormalities consistent with complicated pouchitis in seven of nine examinations, with findings including pouch wall thickening, abnormal wall enhancement, peripouch fluid collection, sinus and fistula tract formation, lymphadenopathy, and peripouch stranding and fatty proliferation. MRI findings of complicated pouchitis should raise the suspicion of Crohn's disease and should prompt further investigation.

Diffuse gastroduodenitis and pouchitis associated with ulcerative colitis

We experienced a very rare case of ulcerative colitis (UC) accompanied with analogous lesions in the stomach, duodenum, and ileal J -pouch. Ileal J-pouch anal anastomosis was performed on a 29-year old woman in 1996. Six years later, she was admitted again to our hospital because of epigastralgia, nausea, watery diarrhea and low fever. Based on the results of endoscopic examination, we diagnosed it as pouchitis. Moreover, on hypotonic duodenography, expansion of the duodenal bulb and the descending portion were poor. Kerckring folds disappeared with typical lead-pipe appearance. The pathogenesis of the gastric and duodenal lesion in this patient was similar to that of the colonic lesions of UC. For the gastroduodenal lesions in this patient, symptomatic remission was obtained following administration of crushed mesalazine tablets (1500 mg/d) for 14 d with continuous administration of omeprazole. Firstly we used ciprofloxacin to treat pouchitis. On the fifth day, she got a fever because of catheter infection. In the catheter culture, methicillin-resistant Staphylococcus aureus (MRSA) was detected. Therefore we changed ciprofloxacin to vancomycin hydrochloride (Vancomycin^®). Vancomycin was very effective, and the stool frequency dramatically improved in three days. Now she continues to take mesalazine, but her condition is stable and there has been no recurrence of pouchitis.

Collagenous pouchitis

Collagenous colitis is characterised by watery diarrhoea, normal colonic mucosa on endoscopy, diffuse colitis with surface epithelial injury, and a distinctive thickening of the subepithelial collagen table on histology. Some patients can develop medically refractory collagenous colitis, in which case they may require surgical intervention. This is the first report of collagenous pouchitis in a collagenous colitis patient with proctocolectomy and ileal pouch-anal anastomosis. A patient with medically refractory collagenous colitis who underwent a total proctocolectomy and ileal pouch-anal anastomosis was sequentially evaluated with an endoscopy and histology of the colon, distal small intestine, and ileal pouch. A 58-year-old female had a 10-year history of collagenous colitis before having a total proctocolectomy and ileal pouch-anal anastomosis for medically refractory disease. The histologic features of collagenous colitis were present in all colon and rectum biopsy or resection specimens, but were absent in the distal ileum specimen. The post-operative course was complicated by persistent increase of stool frequency, abdominal cramps, and incontinence. A pouch endoscopy was performed 3 years after ileal pouch-anal anastomosis which showed the histologic features of collagenous colitis in the ileal pouch, collagenous pouchitis, while the pre-pouch neo-terminal ileum had no pathologic changes. After antibiotic therapy, the histologic changes of collagenous pouchitis resolved. This is the first reported case of collagenous pouchitis. Since the abnormal collagen table and its associated features were only present in the pouch and absent in the neo-terminal ileum, and the patient had histologic improvement after antibiotic therapy, it would suggest that faecal stasis and bacterial load may play a role in the pathogenesis.

Systematic review: the management of pouchitis

Pouchitis is the most common complication following proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. We aim at discussing relevant information on epidemiology, clinical features, risk factors, diagnostic testing, differential diagnosis and treatment of this idiopathic inflammatory condition. A computerized search of PubMed was performed with the search term 'pouchitis', limited to English papers on humans. This strategy identified 514 references. Relevant articles were selected from this list. In addition, the reference list for each of the selected articles was reviewed to identify any additional references. Pouchitis occurs in up to 60% of patients after ileal pouch-anal anastomosis for ulcerative colitis, and has characteristic clinical, endoscopic and histological features. The most important test for diagnosis is pouch endoscopy with biopsy. Antibiotics remain the mainstay of treatment, and other options are discussed for those patients who are refractory to antibiotic therapy.

The ileoanal pouch procedure in the long–term perspective: a critical review

An ileo-pouch anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis. Clinical results on the pelvic pouch procedure have often been encouraging; when confronted with the different surgical options, the majority of patients select IPAA as the best operation. However, even if IPAA is a great innovation, it is by no means the first choice for all patients. For patients old enough to join in a responsible discussion, the pros and cons of the various operations must be carefully described; the choice of surgical procedure must meet the patient's wishes and appear soundly based to the surgeon. The young age of most patients has to be considered and a long follow-up time is required to establish whether and, if so, to what extent the operation may adversely impact the patient's continence, sex life, fertility, and quality of life. The risk of cancer transformation in the residual rectal mucosa in the muscular or columnar cuff is another important factor that may influence the eventual decision. This article critically reviews our experience and the literature.

[Diagnosis and medical treatment of pouchitis in ileal pouch-anal anastomosis in patients with ulcerative colitis]

Pouchitis is a common and long-term complication of ileal pouch-anal anastomosis in patients with underlying ulcerative colitis. Combination with clinical symptoms, endoscopic and histopathological findings are required to make accurate diagnosis. Ciprofloxacin and metronidazole are effective in patients with acute pouchitis. Probiotics may be useful in maintaining regression and preventing from remission. Immunomodulating agents are also useful in chronic pouchitis.

Management of pouch dysfunction or pouchitis with an ileoanal pouch

Pouchitis, a non-specific inflammation of the ileal reservoir, is the most frequent long-term complication after pouch surgery for ulcerative colitis. Incidence rates vary widely. The etiology is still unknown, but genetic susceptibility and fecal stasis with bacterial overgrowth seem to be important factors. A clinical diagnosis should be always confirmed by endoscopy and histology, and Pouchitis Disease Activity Index (PDAI), based on clinical symptoms, endoscopic appearance and histologic findings, represents an objective and reproducible scoring system for pouchitis. The treatment of pouchitis is largely empiric given the few controlled studies available. Antibiotics, especially metronidazole and ciprofloxacin, are the therapy of choice. Chronic pouchitis occurs in about 10-15% of patients; in these cases, further diagnostic tests should be performed to exclude alternative diagnoses. Highly concentrated probiotics (VSL#3) have been shown to be effective in preventing the onset and relapse of pouchitis.

Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

BACKGROUND & AIMS

Increased stool frequency, urgency, and abdominal pain in patients with ileal pouch-anal anastomosis (IPAA) may be due to inflammatory conditions, including pouchitis, cuffitis, or Crohn's disease or noninflammatory conditions such as irritable pouch syndrome. Distinction among these entities requires pouch endoscopy and biopsy. Noninvasive means of diagnosis are preferable.

METHODS

Sixty consecutive subjects with IPAA for inflammatory bowel disease had measurements of fecal lactoferrin and alpha1-antitrypsin and underwent pouch endoscopy with biopsy, with calculation of the pouchitis disease activity index in a prospective cross-sectional study.

RESULTS

Symptomatic patients with an inflammatory condition had significantly higher fecal lactoferrin concentrations (median, 176.0 microg/mL, interquartile range [IQR] 79.0-450.8) compared with those with a noninflammatory condition (median, 4.8 microg/mL; IQR, 1.2-11.0) or those who were asymptomatic (median, 7.8 microg/mL; IQR, 1.4-12.9), P < 0.001. At a cutoff level of 7 microg/mL, fecal lactoferrin could distinguish patients with irritable pouch syndrome from those with pouchitis, cuffitis, or Crohn's disease with a sensitivity of 100% and specificity of 85%. Fecal alpha1-antitrypsin was not able to distinguish symptomatic patients with and without an inflammatory condition.

CONCLUSIONS

Fecal lactoferrin can serve as a sensitive and noninvasive initial screening test in an algorithm for evaluation of symptomatic patients with IPAA. If fecal lactoferrin levels are low (<7 microg/mL), IPS can be diagnosed. If fecal lactoferrin levels are high, pouch endoscopy with biopsy is warranted to distinguish among different causes of inflammation. Longitudinal studies are needed to define better the role of this test in the management of patients with IPAA.

The diagnosis and treatment of pouchitis in inflammatory bowel disease

The ileal pouch anal anastomosis (IPAA) procedure has become the preferred surgical option for most patients with ulcerative colitis who require surgical removal of the colorectum. The vast majority of patients with this new anatomy will either not develop pouchitis or develop a few discrete episodes of acute pouchitis. However approximately one fourth of patients will develop recurrent pouchitis, with 5% being categorized as chronic pouchitis requiring maintenance therapy or, on rare occasion, pouch excision. Factors that are associated with an increased risk of pouchitis include primary sclerosing cholangitis, extraintestinal manifestations, and nonsmokers. Controversy surrounds other risk factors such as extent of colitis, backwash ileitis, preoperative pANCA levels, and carrying a specific allele for IL-1 receptor antagonist. The etiology of pouchitis is unknown, but theories range from genetic susceptibility, bacterial overgrowth, ischemia, and fecal stasis, to a recurrence of ulcerative colitis in the pouch, a missed diagnosis of Crohn's disease, or possibly a novel third form of inflammatory bowel disease. Some patients with symptoms of pouchitis will not have inflammation of the pouch, but rather, irritable pouch syndrome. Thus, endoscopic investigation with biopsy is important for declaring whether a patient has pouchitis. Indeed, the more commonly used scores, such as the pouch disease activity index, incorporate both endoscopic and histologic criteria. Not surprisingly, treatment options for patients with pouchitis resemble that of regular inflammatory bowel disease, although there have only been a few controlled trials. Antibiotics are the mainstay of therapy, with metronidazole and ciprofloxacin demonstrating benefit in controlled trials. Probiotics are effective for maintaining remission of pouchitis. Mesalamine, corticosteroids, and immunomodulators have been used with some success. Occasionally, patients with well-documented ulcerative colitis as the indication for IPAA will develop what appears to be Crohn's disease of the pouch, on the basis of granulomatous inflammation, pre-pouch ileitis, or fistulae. The treatment is similar to Crohn's disease, including the use of infliximab. Dysplasia within the pouch mucosa itself is quite rare. Reports of dysplasia occurring in patients with IPAA are usually due to neoplastic change within the residual cuff of rectal or transition zone mucosa just below the pouch, rather than in the ileal mucosa of the pouch. With further elucidation of the genetic basis for inflammatory bowel disease, we should be able to more accurately classify patients with ulcerative colitis and Crohn's disease genotypically. Hopefully, this will also bring more clarity to the heterogeneous population of patients with pouchitis and allow for more focused therapeutic strategies.

Diagnostic difficulties in pouchitis--experience from a single institution

The aim of the study was to analyze the clinical, endoscopic and histological signs of pouchitis in patients operated on because of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Between 1984 and 2002, the Department of Surgery carried out 218 restorative proctocolectomies in patients with UC and 120 in FAP patients. The follow-up to assess the intensity of inflammatory changes included 110 patients: 72 UC and 38 FAP. During the endoscopic examination, samples were taken for routine histological examinations. The histological assessment was based on the so-called Moskwitz's Histological System. Acute pouchitis is diagnosed if the score is > or =4, and chronic condition--if the score is > or =4. We used a modified PDAI scale to analyze the symptoms, taking into account the microscopically detectable histological features of chronic pouchitis. The clinical symptoms of pouchitis were revealed in 28 patients (25.5%), endoscopic symptoms in 36 patients (32.7%), and histological parameters in 48 patients (28-58.3% with > or =4 score of acute pouchitis and 20-41.7% with > or =4 score of chronic pouchitis). The signs of acute and chronic pouchitis were evident in endoscopy and histology, with no clinical features observed in many cases. Patients with symptoms of chronic pouchitis require a continuous follow-up.

Treatment of Pouchitis with Dehydroepiandrosterone (DHEA) - a Case Report

BACKGROUND

Dehydroepiandrosterone (DHEA) inhibits activation of nuclear factor kappa B (NF-kappaB), which is known to be activated in inflammatory lesions of ulcerative colitis, via PPARalpha. In a pilot trial DHEA was effective for the treatment of active ulcerative colitis. Pouchitis is a common complication after proctocolectomy for ulcerative colitis and still a therapeutical challenge.

CASE

DHEA 200 mg/d was tested in chronic active pouchitis in a 35-year-old female patient. DHEA was given for eight weeks, and follow up for further eight weeks was performed. The number of stools dropped from 15-18/d to 8/d, the addition of mucus, which was observed initially, was absent during treatment. The consistence of stools improved from liquid/soft to soft/solid. Abdominal pain resolved and endoscopical signs of inflammation improved. Eight weeks after termination of treatment with DHEA, the patient again suffered from 12 to 18 soft to liquid stools per day and mild abdominal pain.

CONCLUSION

Therapeutic effects of DHEA in pouchitis should be evaluated systematically.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis

OBJECTIVE

Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis.

METHODS

Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data.

RESULTS

Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses.

CONCLUSIONS

Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.

Diagnosis and treatment of patients with pouchitis

Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis in patients with underlying ulcerative colitis. Clinical symptoms of pouchitis are not specific, and they can be caused by other conditions such as rectal cuff inflammation and irritable pouch syndrome. Therefore, to make an accurate diagnosis, endoscopic evaluation together with symptom assessment is necessary. Among five available treat-first and test-first strategies, the initial approach with pouch endoscopy without histology was the most cost-effective strategy for the diagnosis of pouchitis. On the basis of clinical course, pouchitis can be classified into acute, relapsing and chronic forms. Pouchitis can also be classified into three categories based on the response to antibacterial therapy: antibacterial-responsive; antibacterial-dependent; and antibacterial-resistant. Metronidazole and ciprofloxacin are both effective in treating acute pouchitis. Although antibacterial therapy can induce and maintain remission, probiotics such as VSL#3 can also be used as to maintain clinical remission and prevent relapse in patients with relapsing or chronic pouchitis. For patients with chronic pouchitis that is resistant to antibacterials, therapy with anti-inflammatory agents and immunomodulators is often required.

Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis

PURPOSE

Pouchitis is the most common complication of ileal pouch-anal anastomosis for ulcerative colitis. Our previous study suggested that symptoms alone are not reliable for the diagnosis of pouchitis. The most commonly used diagnostic instrument is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom, endoscopy, and histology. Despite its popularity, the pouchitis disease activity index has mainly been a research tool because of costs of endoscopy (especially with histology), complexity in calculation, and time delay in determining histology scores. It is not known whether pouch endoscopy without biopsy can reliably diagnose pouchitis in symptomatic patients. The aim of the present study was to determine whether omitting histologic evaluation from the pouchitis disease activity index significantly affects the sensitivity and specificity of diagnostic criteria for pouchitis.

METHODS

Ulcerative colitis patients with an ileal pouch-anal anastomosis and symptoms suggestive of pouchitis were evaluated. Patients with chronic refractory pouchitis and Crohn's disease were excluded. Patients with pouchitis disease activity index scores of seven or more were diagnosed as having pouchitis. Different diagnostic criteria were compared on the basis of the pouchitis disease activity index component scores. Nonparametric receiver-operating-characteristic curves were used to measure proposed pouchitis scores' diagnostic accuracy compared with diagnosis from the pouchitis disease activity index. The receiver-operating-characteristic area under the curve measured how much these diagnostic strategies differed from each other.

RESULTS

Fifty-eight consecutive symptomatic patients were enrolled; 32 (55 percent) patients were diagnosed with pouchitis. With the use of the pouchitis disease activity index as a criterion standard, the use of only symptom and endoscopy scores (modified pouchitis disease activity index) produced an area under the curve of 0.995. Establishing a cut-point of five or more for diseased patients resulted in a sensitivity equal to 97 percent and specificity equal to 100 percent.

CONCLUSIONS

Diagnosis based on the modified pouchitis disease activity index offers similar sensitivity and specificity when compared with the pouchitis disease activity index for patients with acute or acute relapsing pouchitis. Omission of endoscopic biopsy and histology from the standard pouchitis disease activity index would simplify pouchitis diagnostic criteria, reduce the cost of diagnosis, and avoid delay associated with determining histology score, while providing equivalent sensitivity and specificity.

Assessment of mucosal inflammation and circulation in response to probiotics in patients operated with ileal pouch anal anastomosis for ulcerative colitis

BACKGROUND

Pouchitis is a common and troublesome condition, and a disturbed microbiological flora and mucosal blood flow in the pouch have been suggested as possible causes. Laser Doppler flowmetry (LDF) has been used successfully to measure gastric and colonic mucosal perfusion in humans. The aim of this study was to evaluate the effect of intervention with probiotics on ileal pouch inflammation and perfusion in the pouch, assessed by endoscopy, histology, fecal calprotectin and LDF.

METHODS

A fermented milk product (Cultura; 500 ml) containing live lactobacilli (La-5) and bifidobacteria (Bb-12) was given daily for 4 weeks to 10 patients operated with ileal-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Mucosal perfusion was measured with LDF and the degree of inflammation was examined at predefined levels of the distal bowel by endoscopy and histology. Stool samples were cultured for lactobacilli and bifidobacteria and calprotectin were measured before and after intervention.

RESULTS

The LDF measurements were reproducible in the pelvic pouch at each of the predefined levels, but did not change after intervention. The mucosal perfusion was reduced in the distal compared to the proximal part of the pouch. Calprotectin levels did not change significantly after intervention. The median endoscopic score for inflammation was significantly reduced by 50% after intervention, whereas the histological score did not change significantly.

CONCLUSION

The results suggest that probiotics primarily act superficially, with change of gross appearance of the mucosa at endoscopy, but without significant effect on histological picture, mucosal perfusion or faecal calprotectin, during a relatively short period of 4 weeks.