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Abstract
: Restorative proctocolectomy with ileal pouch-anal anastomosis is commonly used in the management of ulcerative colitis. Inflammation of the ileal pouch reservoir, or pouchitis, is a common complication of ileal pouch-anal anastomosis that is incompletely understood. Risk factors including nonsmoker status and primary sclerosing cholangitis have been linked with pouchitis development, but the etiopathogenesis of pouchitis remains poorly defined. Pouchitis is more commonly a complication of ileal pouch-anal anastomosis performed in patients with ulcerative colitis, and similar to ulcerative colitis, chronic pouchitis is associated with extraintestinal manifestations and other diseases of immune origin, suggesting overlap in the disease pathogenesis. It is becoming apparent that pouchitis encompasses clinically distinct subtypes based on the response or lack of response to antibiotic therapy. There is also emerging evidence of the role of autoimmunity in a subgroup of patients with pouchitis, including patients with concurrent primary sclerosing cholangitis, seropositivity for immunoglobulin G4, or infiltration of immunoglobulin G4-expressing plasma cells in the pouch mucosa. The identification of underlying autoimmunity may have important clinical implications in the diagnosis, subclassification, and management of pouchitis.
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Singh S, Sharma PK, Loftus EV, Pardi DS. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013; 37:867-75. [PMID: 23480145 DOI: 10.1111/apt.12274] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/09/2013] [Accepted: 02/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal pouch-anal anastomosis (IPAA). AIM To perform a systematic review with meta-analysis of studies evaluating the association of ANCA and ASCA status with risk of acute and chronic pouchitis after IPAA. METHODS We searched multiple databases (upto September 2012) for studies reporting ANCA and/or ASCA status along with risk of acute or chronic pouchitis after IPAA in adults with ulcerative colitis (UC). We abstracted odds ratio (OR) or raw data from the individual studies to calculate summary OR estimates with 95% CIs using random-effects model. RESULTS Eight studies reporting 184 cases of acute pouchitis and six studies reporting 151 cases of chronic pouchitis were included. The odds of chronic pouchitis were 76% higher in ANCA-positive patients than ANCA-negative (six studies; OR: 1.76; 95% CI: 1.19-2.61; P < 0.01). ASCA-positivity was not associated with the risk of chronic pouchitis (three studies; OR: 0.89; 95% CI: 0.49-1.59; P = 0.68). Neither ANCA (eight studies; OR: 1.54; 95% CI: 0.79-3.02; P = 0.21) nor ASCA-positivity (two studies; OR: 1.28; 95% CI: 0.25-6.54; P = 0.77) were associated with the risk of acute pouchitis. CONCLUSIONS The risk of chronic pouchitis after IPAA is higher in ANCA-positive patients, but the risk of acute pouchitis is unaffected by ANCA status. ASCA status was not associated with the risk of acute or chronic pouchitis. This information may be used to counsel UC patients regarding their risk of pouchitis after IPAA.
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Affiliation(s)
- S Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Prideaux L, De Cruz P, Ng SC, Kamm MA. Serological antibodies in inflammatory bowel disease: a systematic review. Inflamm Bowel Dis 2012; 18:1340-55. [PMID: 22069240 DOI: 10.1002/ibd.21903] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 08/25/2011] [Indexed: 12/13/2022]
Abstract
The diagnosis of inflammatory bowel disease (IBD) is traditionally based on a combination of clinical, endoscopic, histological, and radiological criteria. However, further testing is needed in cases of diagnostic uncertainty and in predicting disease course. This systematic review focuses on the potential for 10 serological antibodies to fill these roles: pANCA, ASCA, anti-OmpC, anti-CBir1, anti-I2, ALCA, ACCA, AMCA, anti-L, and anti-C. We discuss their prevalence in IBD and health; their role in disease diagnosis and risk stratification; their stability over time; their presence in unaffected relatives; their association with genetic variants; and differences across ethnic groups. Serological antibodies have some role in primary diagnosis and in differentiating between Crohn's disease and ulcerative colitis. In indeterminate colitis, preoperative measurement of serological antibodies can help to predict the likelihood of complications among patients undergoing pouch surgery. The combined presence and magnitude of a large panel of antibodies appear to be of value in predicting disease progression. There is currently insufficient evidence to recommend the use of antibody testing to predict responses to treatment or surgery in patients with IBD.
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Affiliation(s)
- Lani Prideaux
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Australia
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4
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Abstract
Ileal pouch-anal anastomosis is the procedure of choice in the surgical management of refractory ulcerative colitis. Pouchitis affects up to 60% of patients following ileal pouch-anal anastomosis for ulcerative colitis. It overlaps significantly with ulcerative colitis such that improvements in our understanding of one will impact considerably on the other. The symptoms are distressing and impinge significantly on patients' quality of life. Despite 30 years of scientific and clinical investigation, the pathogenesis of pouchitis is unknown; however, recent advances in molecular and cell biology make a synergistic hypothesis possible. This hypothesis links interaction between epithelial metaplasia, changes in luminal bacteria (in particular sulfate-reducing bacteria), and altered mucosal immunity. Specifically, colonic metaplasia supports colonization by sulfate-reducing bacteria that produce hydrogen sulfide. This causes mucosal depletion and subsequent inflammation. Although in most cases antibiotics lead to bacterial clearance and symptom resolution, immunogenetic subpopulations can develop a chronic refractory variant of pouchitis. The aims of this paper are to discuss proposed pathogenic mechanisms and to describe a novel mechanism that combines many hypotheses and explains several aspects of pouchitis. The implications for the management of both pouchitis and ulcerative colitis are discussed.
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Vermeire S, Assche GV, Rutgeerts P. Role of biomarkers in the diagnosis of inflammatory bowel disease. ACTA ACUST UNITED AC 2007; 1:481-8. [DOI: 10.1517/17530059.1.4.481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Maunder RG, Greenberg GR, Hunter JJ, Lancee WJ, Steinhart AH, Silverberg MS. Psychobiological subtypes of ulcerative colitis: pANCA status moderates the relationship between disease activity and psychological distress. Am J Gastroenterol 2006; 101:2546-51. [PMID: 17029612 PMCID: PMC2923655 DOI: 10.1111/j.1572-0241.2006.00798.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions. METHODS In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination, and endoscopy using the St. Mark's index, and depressive symptoms and health anxiety were measured with self-report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated. RESULTS In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation = 0.48, p < 0.001) and for disease activity-health anxiety (partial correlation = 0.64, p < 0.001), whereas in 74 pANCA positive subjects, no relationships were found (disease activity-depression: partial correlation = 0.18, p= 0.14; disease activity-health anxiety: partial correlation = 0.20, p= 0.09). The differences in the strength of correlation between pANCA positive and pANCA negative subjects were statistically significant for both disease activity-depression (z = 2.0, p= 0.02) and activity-health anxiety (z = 3.3, p < 0.001). CONCLUSIONS pANCA status demarcates psychobiologically distinct subtypes of UC, such that the absence of pANCA is associated with greater psychobiological interaction. These findings have implications for clinical care and understanding the pathophysiology of intestinal inflammation.
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7
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Luckschander N, Allenspach K, Hall J, Seibold F, Gröne A, Doherr MG, Gaschen F. Perinuclear Antineutrophilic Cytoplasmic Antibody and Response to Treatment in Diarrheic Dogs with Food Responsive Disease or Inflammatory Bowel Disease. J Vet Intern Med 2006. [DOI: 10.1111/j.1939-1676.2006.tb02849.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Garcia RM, Brody F, Miller J, Ponsky TA. Parastomal herniation of the gallbladder. Hernia 2005; 9:397-9. [PMID: 15912259 DOI: 10.1007/s10029-005-0340-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2004] [Accepted: 03/16/2005] [Indexed: 10/25/2022]
Abstract
Parastomal hernias can occur in up to 31% of patients following an enterostomy (Cheung in Aust N Z J Surg 65:808-811, 1995). This type of hernia develops through an intentional fascial defect. Commonly, most parastomal hernias involve a reducible segment of omentum, small bowel, or colon. Typically, these hernias are asymptomatic and associated rarely with strangulation or obstruction. Patient preference and clinical scenario may dictate management of these hernias. Non-operative management of parastomal hernias includes abdominal binders and enterostomy belts. Operative management includes a host of options including mesh repair, a new stoma site, or revision. This paper documents the first reported case of a parastomal hernia involving the gallbladder. Optimal technique and site placement of a stoma are also discussed.
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Affiliation(s)
- R M Garcia
- Department of Surgery, The George Washington University Medical Center, 2150 Pennsylvania Ave., NW Suite 6B, Washington, DC 20037, USA
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9
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Abstract
OBJECTIVE The aim of this study was to audit the results of parastomal hernia repair. METHODS A retrospective review was made of all patients having parastomal hernia repair at 2 teaching hospitals over a 12-year period. RESULTS Forty-three patients had 51 parastomal hernia repairs. Three types of hernia repair were used: 14 (28%) local suture, 19 (37%) local mesh repair and 18 (35%) stoma relocation. Three patients died and significant complications occurred in 65% of repairs. Parastomal hernia recurred in 18 (38%) of repairs. This was greatest with a sutured repair (59%) and least in patients having stoma relocation (24%). Repair with mesh was associated with a 39% recurrence rate. No significant statistical difference was found for the results of these repairs. CONCLUSION Parastomal hernia repair is associated with high rates of morbidity, mortality and recurrence. Repair should not be undertaken without a good indication.
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Affiliation(s)
- N Rieger
- The University Departments of Surgery, The Queen Elizabeth and Royal Adelaide Hospitals, Adelaide, South Australia.
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10
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Gisbert JP, Gomollón F, Maté J, Pajares JM. [The role of anti-neutrophil cytoplasmic antibodies (ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:312-24. [PMID: 12732107 DOI: 10.1016/s0210-5705(03)70365-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- J P Gisbert
- Servicio de Aparato Digestivo. Hospital Universitario de la Princesa. Madrid. Spain.
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11
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Affiliation(s)
- Uma Mahadevan
- Department of Medicine, University of California, San Fancisco, USA
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12
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Jani AL, Hamilos D. Bloody diarrhea, fever, and pancytopenia in a patient with active ulcerative colitis. Ann Allergy Asthma Immunol 2003; 90:383-8. [PMID: 12722958 DOI: 10.1016/s1081-1206(10)61820-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alpa L Jani
- Department of Allergy and Immunology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Affiliation(s)
- Alon Pikarsky
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston 33331, USA
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14
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Esters N, Vermeire S, Joossens S, Noman M, Louis E, Belaiche J, De Vos M, Van Gossum A, Pescatore P, Fiasse R, Pelckmans P, Reynaert H, Poulain D, Bossuyt X, Rutgeerts P. Serological markers for prediction of response to anti-tumor necrosis factor treatment in Crohn's disease. Am J Gastroenterol 2002; 97:1458-62. [PMID: 12094865 DOI: 10.1111/j.1572-0241.2002.05689.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The use of monoclonal anti-tumor necrosis factor (TNF) antibodies (infliximab, Remicade) is a new therapeutic approach for severe refractory luminal or fistulizing, Crohn's disease (CD). However, up to 30% of patients do not respond to this treatment. So far, no parameters predictive of response to anti-TNF have been identified. Our aim was to determine whether serological markers ASCA (anti-Saccharomyces cerevisiae antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibodies) could identify Crohn's patients likely to benefit from anti-TNF therapy. METHODS Serum samples of 279 CD patients were analyzed for ASCA and pANCA before anti-TNF therapy. A blinded physician determined clinical response at week 4 (refractory luminal CD) or week 10 (fistulizing CD) after the first infusion of infliximab (5 mg/kg). RESULTS Overall, there was no relationship between ASCA or pANCA and response to therapy. However, lower response rates were observed for patients with refractory intestinal disease carrying the pANCA+/ASCA- combination, although this lacked significance (p = 0.067). CONCLUSIONS In this cohort of infliximab-treated patients, neither ASCA nor pANCA could predict response to treatment. However, the combination pANCA+/ASCA- might warrant further investigation for its value in predicting nonresponse in patients with refractory luminal disease.
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Affiliation(s)
- N Esters
- Department of Gastroenterology, UZ Gasthuisberg Leuven, Belgium
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15
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Finkelstein SD, Sasatomi E, Regueiro M. Pathologic features of early inflammatory bowel disease. Gastroenterol Clin North Am 2002; 31:133-45. [PMID: 12122728 DOI: 10.1016/s0889-8553(01)00009-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Often the pathologic changes of IBD are subtle and may not be present in a proportion of biopsy specimens. In cases of early disease, the changes may be missed, and additional specimens should be taken after a period of time. Modifying factors, such as prebiopsy treatment and coexisting disease, should be considered. A forum to review cases and allow for communication between gastroenterologists and pathologists is especially useful for clinicopathologic correlation and assignment of a working diagnosis to each case. Careful attention to the pathologic features of early UC and CD would be most useful when evaluating new therapies for IBD.
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Affiliation(s)
- Sydney D Finkelstein
- Department of Pathology, Division of Gastroenterology, Nutrition and Hepatology, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH A610.2, Pittsburgh, PA 15213, USA
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Osangthamnont C, Manatsathit S, Pongprasopchai S, Viriyataveekul R, Chaihirunkarn S, Leelakusolvong S, Boonyapisit S. Antibodies to neutrophil cytoplasma in patients with ulcerative colitis and their first-degree relatives in Thailand. J Gastroenterol Hepatol 2001; 16:866-71. [PMID: 11555099 DOI: 10.1046/j.1440-1746.2001.02546.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The prevalence of perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) does not significantly vary in ethnically diverse populations. The prevalence of p-ANCA is high in ulcerative colitis and primary sclerosing cholangitis. While the prevalence of ulcerative colitis in Asian populations is low, it is interesting to know the prevalence of p-ANCA in such a population. METHODS Sera from 33 cases of ulcerative colitis diagnosed during the last 10 years at the diarrhea clinic, Division of Gastroenterology, Siriraj Hospital, were prospectively compared with case controls consisting of 15 cases of diarrhea from non-inflammatory bowel diseases and 25 non-diarrheic patients. Indirect immunofluorescence assay was used to detect p-ANCA in all the sera. RESULTS Positive p-ANCA tests were found in 13 of the 33 patients with ulcerative colitis and in one of the 40 controls. Sensitivity of the test was 39.4% and the specificity was 97.5%. The one patient with positive p-ANCA in the control group was the patient with irritable bowel syndrome. Of the 13 p-ANCA-positive ulcerative colitis patients, two cases were found to have proctosigmoiditis, seven cases had left-sided colitis, and four cases had pancolitis. Perinuclear antineutrophil cytoplasmic antibodies was one of the 22 cases of first-degree relatives of ulcerative colitis patients (22 relatives from 12 index ulcerative colitis cases). There was no correlation between the positivity of p-ANCA and disease activity, and extent of the disease. CONCLUSION The prevalence of p-ANCA in Thai patients with ulcerative colitis (39.4%) is lower than that in the Western population. Although the prevalence of p-ANCA is low in the Thai population, it should serve as a useful tool in diagnosing ulcerative colitis in this part of the world where the disease is uncommon and difficult to diagnose. The negativity of p-ANCA in almost all first-degree relatives of Thai ulcerative colitis patients should be further elucidated.
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Affiliation(s)
- C Osangthamnont
- Division of Gastroenterology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Koutroubakis IE, Petinaki E, Mouzas IA, Vlachonikolis IG, Anagnostopoulou E, Castanas E, Maniatis AN, Kouroumalis EA. Anti-Saccharomyces cerevisiae mannan antibodies and antineutrophil cytoplasmic autoantibodies in Greek patients with inflammatory bowel disease. Am J Gastroenterol 2001; 96:449-54. [PMID: 11232689 DOI: 10.1111/j.1572-0241.2001.03524.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The combined measurement of perinuclear antineutrophil cytoplasmic autoantibodies (pANCA) and anti-Saccharomyces cerevisiae mannan antibodies (ASCA) has recently been suggested as a valuable diagnostic approach in inflammatory bowel disease (IBD). The aim of this study was to assess the value of detecting pANCA and ASCA in the differentiation between ulcerative colitis (UC) and Crohn's disease (CD) in a Greek population with IBD. METHODS Sera were collected from 157 patients with IBD (97 with UC, 56 with CD, and four with indeterminate colitis) and 150 healthy controls. Determination of pANCA was performed by a standard indirect immunofluorescence technique on ethanol-fixed granulocytes and ASCA by an ELISA assay. RESULTS In patients with UC, sensitivity, specificity, positive predictive value, and negative predictive value of the pANCA test was 67%, 84%, 93%, and 46% respectively. These values did not change significantly when the combination of positive pANCA and negative ASCA was used. ASCA test in diagnosing CD yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 39%, 89%, 54%, and 81%. The combination of pANCA negative and ASCA positive increased the positive predictive value to 77% and it was associated with small bowel disease. CONCLUSIONS A positive pANCA test in Greek patients has a diagnostic value in confirming a diagnosis of UC. Measurement of pANCA and ASCA together has a rather limited value in the differential diagnosis between UC and CD but may be of help in studying disease heterogeneity.
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Affiliation(s)
- I E Koutroubakis
- Department of Gastroenterology, University Hospital Heraklion, Crete, Greece
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Balbir-Gurman A, Schapira D, Nahir M. Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis. Semin Arthritis Rheum 2001; 30:242-8. [PMID: 11182024 DOI: 10.1053/sarh.2001.19960] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). METHODS The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed. RESULTS The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. CONCLUSIONS Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies.
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Affiliation(s)
- A Balbir-Gurman
- B. Shine Department of Rheumatology, Rambam Medical Center, and the Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Roozendaal C, Kallenberg CG. Are anti-neutrophil cytoplasmic antibodies (ANCA) clinically useful in inflammatory bowel disease (IBD)? Clin Exp Immunol 1999; 116:206-13. [PMID: 10337008 PMCID: PMC1905286 DOI: 10.1046/j.1365-2249.1999.00905.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Since the first detection of ANCA in IBD, numerous studies have dealt with their prevalence, antigenic specificities, clinical significance, pathophysiological role, and their induction. This review summarizes the information obtained from those studies and shows that ANCA are not directly useful as diagnostic and prognostic factors in IBD. ANCA were detected in 50-85% of patients with ulcerative colitis (UC) and 10-20% of patients with Crohn's disease (CD). Multiple target antigens are recognized by these autoantibodies, including both cytoplasmic and nuclear proteins. A pathophysiological role for ANCA in IBD is far from clear. On the one hand, it is suggested that ANCA are genetic markers of susceptibility for IBD, and on the other hand, the induction of ANCA in those diseases may just be an epiphenomenon of chronic inflammation. We discuss recent evidence that ANCA may be induced by a break-through of tolerance towards bacterial antigens.
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Affiliation(s)
- C Roozendaal
- Department of Clinical Immunology, University Hospital Groningen, Groningen, The Netherlands
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20
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Kaditis AG, Perrault J, Sandborn WJ, Landers CJ, Zinsmeister AR, Targan SR. Antineutrophil cytoplasmic antibody subtypes in children and adolescents after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr 1998; 26:386-92. [PMID: 9552133 DOI: 10.1097/00005176-199804000-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perinuclear antineutrophil cytoplasmic antibodies occur frequently in adult patients with chronic pouchitis after colectomy and ileal pouch-anal anastomosis for ulcerative colitis. The purpose of the study was to determine the prevalence of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in children and adolescents who undergo colectomy and ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis. METHODS Five groups of children and adolescents (age, <20 years) were studied, with the following histories: acute pouchitis and history of ulcerative colitis; chronic pouchitis and history of ulcerative colitis; pouchitis with Crohn's disease features and a history of ulcerative colitis; no pouchitis and a history of ulcerative colitis; and familial adenomatous polyposis, with or without pouchitis. Antineutrophil cytoplasmic antibody levels and titers were detected in postoperative sera by enzyme-linked immunosorbent assay, and positive results were subtyped by indirect immunofluorescence. RESULTS The frequency of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in patients with a history of ulcerative colitis were 67% and 15%, compared with a 0% presence in patients with familial adenomatous polyposis (p < 0.001). There was no significant correlation between the frequency of perinuclear antineutrophil cytoplasmic antibodies and ulcerative colitis patient subgroups (patients with and without pouchitis, 66% and 75%). Similarly, there was no significant correlation between the frequency of cytoplasmic antineutrophil cytoplasmic antibodies among ulcerative colitis patient subgroups (patients with and without pouchitis, 19% and 8%). The frequency of cytoplasmic antineutrophil cytoplasmic antibody in patients with Crohn's disease features (50%), was increased, but this difference was not significant. CONCLUSIONS There is a high frequency of perinuclear antineutrophil cytoplasmic antibodies in children and adolescents who undergo ileal pouch-anal anastomosis for ulcerative colitis, whether or not they have pouchitis. The frequency of cytoplasmic antineutrophil cytoplasmic antibody is lower in this patient population. Additional studies will be required to determine whether the presence of cytoplasmic antineutrophil cytoplasmic antibody is associated with the postoperative development of features of Crohn's disease.
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Affiliation(s)
- A G Kaditis
- Division of Pediatric Gastroenterology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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21
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Ferry GD. The use of antineutrophil cytoplasmic antibodies to determine clinical patterns of ulcerative colitis in children. J Pediatr Gastroenterol Nutr 1998; 26:475-7. [PMID: 9552150 DOI: 10.1097/00005176-199804000-00023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Aitola P, Matikainen M, Mattila J. Hepatobiliary changes in patients with ulcerative colitis, with special reference to the effect of proctocolectomy. Scand J Gastroenterol 1998; 33:113-7. [PMID: 9517518 DOI: 10.1080/00365529850166806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- P Aitola
- Dept. of Surgery, Tampere University Hospital, Finland
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23
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Goldstein NS, Sanford WW, Bodzin JH. Crohn's-like complications in patients with ulcerative colitis after total proctocolectomy and ileal pouch-anal anastomosis. Am J Surg Pathol 1997; 21:1343-53. [PMID: 9351572 DOI: 10.1097/00000478-199711000-00009] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become an established surgical procedure for ulcerative colitis. Occasional patients who have undergone IPAA develop persistent or recurrent episodes of pouchitis (chronic pouchitis), from which a subset also develop gastrointestinal and systemic complications that are identical to those seen in Crohn's disease. These complications include enteric stenoses or fistulas in the pouch or pouch inlet segment, perianal fistulas or abscesses, pouch fistulas, arthritis, iridocyclitis, and pyoderma gangrenosum. The development of Crohn's-like gastrointestinal complications in a patient with chronic pouchitis frequently engenders concern that the pathologist misinterpreted the proctocolectomy specimen as ulcerative colitis instead of Crohn's disease. We describe eight patients who developed chronic pouchitis and Crohn's-like complications after IPAA and total proctocolectomy. In each case, concern was voiced about misinterpretation of the proctocolectomy specimen as ulcerative colitis instead of Crohn's disease after the development of the Crohn's-like complications. Preoperatively, all eight patients had characteristic clinical, radiographic, and pathologic features of ulcerative colitis. Review of the pathology specimens indicated that all eight had ulcerative colitis. Crohn's-like complications are most likely related to chronic pouchitis, which probably is a form of recrudescent ulcerative colitis within the novel environment of the pouch. A diagnosis of Crohn's disease after IPAA surgery should only be made when reexamination of the original proctocolectomy specimen shows typical pathologic features of Crohn's disease, Crohn's disease arises in parts of the gastrointestinal tract distant from the pouch, pouch biopsies contain active enteritis with granulomas, or excised pouches show the characteristic features of Crohn's disease, including granulomas. There were no histologic differences in the total colectomy specimens between the eight ulcerative colitis study patients and 16 control ulcerative colitis patients who had a favorable clinical outcome after IPAA surgery groups. Crohn's-like complications and chronic pouchitis does not necessarily imply an incorrect original interpretation of ulcerative colitis by the pathologist.
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Affiliation(s)
- N S Goldstein
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, Michigan 48324, USA
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Yang P, Oresland T, Järnerot G, Hultén L, Danielsson D. Perinuclear antineutrophil cytoplasmic antibody in pouchitis after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Scand J Gastroenterol 1996; 31:594-8. [PMID: 8789899 DOI: 10.3109/00365529609009133] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has been shown that perinuclear antineutrophil cytoplasmic antibody (P-ANCA) may be associated with pouchitis after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS P-ANCA was studied with the indirect immunofluorescence technique in 76 UC patients after IPAA. Twenty-eight patients had had pouchitis, whereas 48 patients did not. RESULTS P-ANCA was found in 49 of 76 (64.5%) UC patients after IPAA. In patients who had had pouchitis attacks within 1 year of serum sampling (group 1) 12 of 12 (100%) patients had positive P-ANCA. In patients who had had pouchitis attacks 1 or several years before the serum sampling (group 2) 9 of 16 (56.3%) patients had positive P-ANCA. In patients who had not yet had a pouchitis attack (group 3) 28 of 48 (58.3%) were positive. The occurrence of P-ANCA in group 1 was significantly higher than in group 2 (p = 0.01) or group 3 (p = 0.005). No statistically significant difference was found between the occurrence of P-ANCA in group 2 and group 3. Furthermore, we found that the titres of P-ANCA in the pouchitis patients were associated with the observation time since the first pouchitis attack to the time of serum sampling (r = -0.43, p = 0.02) and a pouchitis relapse index (average pouchitis attacks per year, r = 0.47, p = 0.03). CONCLUSIONS P-ANCA was found in UC patients after proctocolectomy with IPAA. Patients with recent (< or = 12 months) or ongoing pouchitis are all P-ANCA-positive. Pouchitis patients with higher P-ANCA titres are more prone to have frequent relapses.
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Affiliation(s)
- P Yang
- Dept. of Medicine, Orebro Medical Centre Hospital, Sweden
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Aisenberg J, Wagreich J, Shim J, Almer S, Peen E, Heimann T, Gelernt IM, Greenstein A, Rubin P, Harpaz N. Perinuclear anti-neutrophil cytoplasmic antibody and refractory pouchitis. A case-control study. Dig Dis Sci 1995; 40:1866-72. [PMID: 7555435 DOI: 10.1007/bf02208648] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Refractory pouchitis (RP) is a debilitating complication of ileal pouch reservoirs that affects approximately 2.5% of patients. Although the cause of RP is unknown, it is frequently hypothesized that it reflects underlying Crohn's disease. Since perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is found in approximately 70% of ulcerative colitis patients but only rarely in Crohn's disease patients, it may help distinguish Crohn's disease from ulcerative colitis. Therefore, to test whether RP reflects "missed" Crohn's disease, we determined the ANCA status of 26 patients with RP. The pANCA was positive in 42% of cases [50% of Kock pouch cases and 33% of ileoanal pull-through (IAPT) cases] and 57% of matched control subjects without pouchitis (N = 42, P = NS). Moreover, 3/6 (50%) of IAPT RP subjects whose signs and symptoms most suggested Crohn's disease tested positive for pANCA. When compared to controls, IAPT cases exhibited significantly more preoperative extraintestinal manifestations (EIMs) of inflammatory bowel disease (P < 0.05). The presence of preoperative EIMs was 100% predictive of postoperative EIMs (P < 0.05). Review of pouch biopsies from cases of RP revealed no pathognomonic histologic features of Crohn's disease. These data confirm our previous suggestion that RP does not reflect underlying Crohn's disease but may be associated with the EIMs of inflammatory bowel disease.
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Affiliation(s)
- J Aisenberg
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
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Asakura H, Sugimura K. HLA, antineutrophil cytoplasmic autoantibody, and heterogeneity in ulcerative colitis. Gastroenterology 1995; 108:597-9. [PMID: 7835603 DOI: 10.1016/0016-5085(95)90091-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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